The Cost of Healthcare

A quick addendum to the previous post…I was reviewing my health insurance account and a few of the claims had come through from this event. The hospital stay at Methodist Mansfield (which I assume to be all-inclusive but may not count the ER visit) ran up a bill of ~$33K. In the normal nebulous policy of insurance payouts, Tricare paid them ~$2.5K for the total amount. It looks like we’re on the hook for $73, which again, may be for everything or just the hospital stay. We paid a similar amount for the ER evaluation at Medical City, so who knows?

Suffice it to say that the cost of healthcare in this country is so beyond the pale it’s hard to fathom. We feel very fortunate to not only have medical insurance, but affordable insurance compared to many people. I think our yearly fees are equivalent to what many people pay each month. This was only an acute event and my total hospitalization was only about 36 hours. Granted, there were some expensive diagnostic studies included, but I can only imagine a long-term stay or the cost of a chronic disease with recurrent hospitalizations or expensive interventions.

A New Year and a Health Scare

Things are going fairly well as I type this on January 3rd, 2024. My health decided to close out the year by reminding me I’m not getting any younger. I’ve had this intermittent vague pain and paresthesias mostly in my left arm for years. I think I may have even posted about it several years ago when I had severe elbow and forearm issues that were aggravated by playing various musical instruments. That was more bilateral, but maybe the left was worse.

Fast forward to this last year and I’ve had recurrent mild issues almost solely in the left arm, starting at the shoulder and going all the way to my fingers. It seemed to predominate in a more ulnar distribution, but the entire limb can be affected. I think prolonged less than ergonomic fixed positions at my desk probably aggravated the issue.

On Christmas Eve we decided to drink the champagne that had been reserved for New Year’s Eve and that rolled into several glasses of wine as I had a pleasant evening watching the Police reunion concert and some other music videos. On Christmas Day I was slightly hungover, but not feeling too bad. I had a decent day - did some baking (rolls, cookies, pizza), walked the dogs, and felt better as the day progressed. As of dinner time, I was feeling fine, although maybe my arm had been acting up during the day, I hadn’t noted any change.

Around 6-7 pm, the pain in the arm increased in severity and was affecting the entire limb from the shoulder down. I couldn’t find a comfortable position and was unable to sit still. I got up and walked around, tried to move the arm through various rotations, and even went outside for a few minutes despite the cold. Nothing I could do was helping and the pain was spreading to my chest and then jaw, while also increasing in severity. I’d characterize the normal pain level at an annoying 2 most of the time, but this episode started as a 6 and was climbing towards 8-9.

I think I took some Tylenol and was still unable to sit still and get comfortable. I thought I might lie down and see if I could sleep it off. That aggravated the jaw and now neck pain, and the severity kept increasing. Being a PA, I recalled from my training in ACLS that one of the instructors referred to an acute myocardial infarction as “infarcting” as opposed to infarction. Meaning, the condition progresses if no actions are taken.

I was downstairs (I think to get Tylenol, but can’t remember the exact sequence of events) when Aeyong got up to get the dogs to go outside since they can be recalcitrant when the weather’s cold or rainy. She immediately noted something was wrong and I told her I thought I might need to go to the ER. She shifted to Defcon 1 in two seconds and was donning clothes and scurrying around the house to grab her purse and keys.

She was taking it more seriously than I was, although the fact this was my first ER trip in 29 years wasn’t lost on me. I decided to go to Medical City in Arlington since it had been recommended to us when Aeyong broke her wrist a few years ago. I think that recommendation was more based on the facility being a Level 1 trauma center as opposed to the quality of the ER.

To their credit, when I presented with chest pain they got me back for evaluation within a few minutes, performing an EKG, CXR, and drawing cardiac labs. We were sent back to the waiting room pending the results. I got a look at the EKG while still in the room and it was “abnormal” based on I think t wave inversion, but there was no significant ST elevation or Q waves that I could spot. Honestly, I had a low index of suspicion for cardiac since I still run regularly and although I have some risk factors, I don’t smoke and my blood pressure has been essentially normal during routine exams.

In the ER my BP was high - 162/98, and this trend would persist during most of this episode. We waited in the ER for several hours, although I think at one point one of the nurses came out and told us the cardiac enzymes were normal. This was my main concern, and with normal enzymes, I was relatively reassured that whatever was going on, it wasn’t cardiac. They kept us for six hours or so, primarily so that serial enzymes could be run and these were also normal.

Ironically, my pain was getting worse and was now becoming more diffuse across my chest, neck, and jaw. It stayed on the left side only, never crossing the midline in the chest, but it was bilateral in the neck and jaw area. Medical City did its main job, but other than that, I was underwhelmed. I was evaluated by a PA, and to his credit, he made sure the most life-threatening issue was cleared, but he never asked about my pain level from a therapeutic standpoint, and at the time he gave us the serial results his attitude was “enzymes are normal” as if there was nothing left to discuss. He never asked about whether my symptoms had changed or worsened, and he never offered any therapy or pain management.

In his defense, I didn’t ask or press the issue because I knew the ER wasn’t my PCM and it was 3:30 in the morning and we were ready to go home. The walk out to the car was some of the worst pain I had felt all night and Aeyong was asking me to go back in or to go to some other ER. I was inclined to believe it had to be neuropathic or musculoskeletal and although quite painful, not life-threatening.

We made it home and I think I took some Tylenol while we tried to get a few hours of sleep. I got up around 7ish and was able to book a follow-up with my PCM for the next morning. Throughout the day the pain never got much better so I tried a hot shower (which helped temporarily) and continued with Tylenol. Aeyong suggested her Robaxin which I tried but didn’t notice any difference. I think it was that night that I couldn’t sleep so I took some leftover Hydrocodone from a previous dental procedure. This gave me a good 4ish hours of uninterrupted sleep.

When I saw my PCM, she was concerned that this might still represent an undiagnosed cardiac or pulmonary issue so she recommended that we go across the street to the Mansfield Methodist ER. We followed her advice and were soon whisked in and went through the same initial workup. EKG, CXR, labs. The ER doc also wanted to run some additional inflammatory markers (ESR, CRP) as well as D-Dimer and BNP. Those markers were all elevated although the cardiac exam was still normal.

She then sent me for a CT Pulmonary Angiogram within the ER to rule out pulmonary embolus and this exam was essentially normal except for some nodules (benign) and a trace pleural effusion that was unlikely to be of any clinical concern. She suggested that there could still be underlying cardiac issues that would need a Cardiologist and further diagnostic studies to rule out. She recommended hospital admission to streamline and expedite the process, stating that it could take weeks or longer if pursued as an outpatient.

I was initially hesitant since this was my first ER visit and possible hospitalization since 1994, most importantly, my first since retirement and I was concerned about cost. Aeyong was adamant that I get a thorough workup and not leave questions unanswered. To her eternal credit, she is always going to push for me to get adequate healthcare and evaluation and not leave things to chance. Despite the possibility of a financially devastating hospital bill, I took Aeyong’s and the ER doc’s recommendation and decided to go forward with the admission.

Bed space was precious, so l was admitted to a just-opened room in the OB ward. The room was quite nice, almost more like a hotel with a private bathroom, desk, recliner, couch, and bed. I was kept under observation and offered some pain relief. I tried T3 with codeine which didn’t do much to blunt the pain. The pain had essentially continued but was coming in waves of severity and then settling down for no discernible reason. It seemed to be centered in the left shoulder and at times would shoot back up to a 7 or 8. After midnight the nurse offered pain relief and I said I didn’t want T3 and would prefer just a gram of Tylenol instead. She then said I could get Hydrocodone if I wanted and I related that it had helped at home, so I decided to have it.

Again, the Hydrocodone helped me get about four hours of sleep. I was NPO as of midnight so they could perform the cardiac stress test. I should mention they had given me nitroglycerin in the ER, and I think it helped some with my chest pain, but can’t state that with confidence. The one outcome I’m relatively sure about is that it gave me a headache and this persisted through the day into the evening. In the morning my primary pain was the headache, as the shoulder and chest pain had died down somewhat.

The night before and earlier that morning I was relatively certain I would need the chemical stress test as I would be unable to perform the treadmill stress test due to my headache and other pain. Once I got down to the testing suite in Radiology, my only pain was the headache and I felt capable of at least trying the TMST. I went through with it and was able to complete the test satisfactorily.

We went back to the room and Aeyong got some food so were able to share a brunch so to speak. Periodically throughout my stay, they would check vitals (Q4h I think) and at times of rest they would be more normal, but if I was up and moving around the BP especially would get higher. Thus far, most testing was normal, except for the D-Dimer, ESR, and CRP. These were all elevated, but they’re non-specific so they mostly only raised more questions rather than providing answers.

I eventually had another radiology tech come to my room in the late afternoon to conduct an echocardiogram there at my bedside. A little after 5 my nurse came in with some papers and notified me I had been discharged by the Cardiologist/Hospitalist. They were confident my issue was non-cardiac and didn’t warrant further testing or hospitalization. I agreed with them and had to get Aeyong out of bed back home to come pick me up. She had run herself ragged going back and forth between home to care for the dogs and coming to the hospital to look after me. Her gas tank is much smaller nowadays and she can quickly drive herself to exhaustion and pain when anything disrupts the normal schedule.

I’m now nine days past the initial episode. The shoulder and arm issues persist, albeit much decreased in severity. I have a follow-up pending on Friday with my PCM, Dr. Avenesyan. My working diagnosis is neuritis or radiculitis that flared up for whatever reason and spread to adjacent structures for reasons undetermined at this point. I’ve been able to walk the dogs every day and I even was able to run on the treadmill yesterday, although a bit slower (5 mph) and for only three miles. I made some changes in my office, removing the wheels from the desk so it’s slightly lower and even putting the keyboard in my lap as I type this long-winded explanation.

I’ll see on Friday whether my PCM wants to send me for further studies. I imagine a CT or MRI and possibly a Neuro/Pain Mgmt eval might be in the cards. All this rambling to relate the conclusion that my threshold for health problems is decreasing as the years pass. I had an acute episode of foot swelling this summer that I think was brought on by excessive sodium intake (snacks) as well as alcohol consumption. I hadn’t drunk any alcohol after that episode up until Thanksgiving. That week saw my frustration with Berklee at an all-time high and accelerated my previous holiday plans by nearly a month.

This rolled into drinking beer for about three weeks straight (we went through four cases of beer in that time frame) as well as not exercising or eating particularly healthy for over two weeks. Ironically, I had returned to my normal schedule for over a week and had run on Sunday without any significant issues. I don’t necessarily think the Christmas Eve champagne and wine were the direct cause of the episode, but a repeating theme in the past few years has been that my health isn’t quite as resilient as it was in my younger days.

I can no longer negate the alcohol and unhealthy food choices with exercise. Now, I have to manage my nutrition more closely than ever before. Alcohol and junk food can manifest as poor health outcomes within just a few days as opposed to being inconsequential (in the short-term) in the past. Whenever I drink now, almost every health metric starts to suffer - sleep quality, nutrition, activity level, mood, cognitive function, motivation, etc.

I haven’t sworn off alcohol permanently, but I’m going to need to shift to small amounts over brief periods, for example, a six-pack shared with Aeyong every few months and never the larger amounts consumed over consecutive days. I’m happy that I never became an alcoholic, but it’s easy for it to become more habitual if you’re complacent about it. To bring things back to the start of this novella, complacency is no longer an option when it comes to my health.

As we age, we have to an active role in managing our health or we’ll be forced to continually rely on the aid of others as we watch our health gradually decline. I’ve set a goal for myself that I won’t have any alcohol or junk food (like Doritos) until I get my weight back under 200 pounds. I had got it down under 210 just in November, but I think I probably gained back another 5-10 pounds since then. Hopefully, once I return to regular exercise and a better diet, those pounds will start coming off. I’ve been largely ambivalent about being overweight for a long time, but I’ve got to take a more holistic view because all aspects of my life tend to take their lead from my physical health.

Spring Has Sprung

In Texas, at least. After a slow start, it appears all of our trees, most of our shrubs and the lawn are making a full recovery from Snowmageddon ‘21. Our biggest tree, the one out front which was planted when they built the house, was probably the slowest to sprout buds. For awhile, I had serious concerns that it didn’t make it through the four day hard freeze back in February. Thankfully, it finally began to display some buds and eventually a full complement of leaves to get that good ‘ole photosynthesis jam going. By current estimates, it’s mainly some potted plants that appear to have met their demise. We have a few shrubs that look dead to me, but Aeyong is optimistic that by cutting them down to their base we’ll encourage some new growth from the roots. We’ll see. If they don’t recover, shrubs are easy enough to replace.

In that horticultural vein, I’ve taken a bit more interest in getting the yard in good trim. I apologize, that wasn’t intended as a pun, but now it is, so there. You’re welcome. We haven’t really gone to any great lengths with our yard, other than regular mowing and seasonal fertilization and occasional seeding. The front has remained pretty thick and healthy, but the backyard has some bare patches, including one large swath of dirt in the back corner. I’m going to try de-thatching and scarifying with, you guessed it, our new de-thatcher/scarifier. Hopefully it will clear up a lot of dead grass and leaves and open up the soil to allow more root growth and nutrient/water transfer where it’s needed. Along with that, I’ve got a big bag of Humic DG which is supposed to enhance nutrient absorption and improve soil structure. It’s a bunch of small spherical granules that disperse into the soil, some of which immediately break down into humic and fulvic acid, combining with essential nutrients and persisting in the soil to allow plant absorption for extended periods of time. The humate portion remains even longer, thereby further extending that nutrient cycle.

I’ve seen a few customer testimonials and just Humic DG alone can make a big difference to yards, plants, and larger agricultural applications. My plan is to de-thatch, scarify, mow up the detritus (I have so few opportunities to use that word, so back off), and then lay down probably half the 40 pound bag of Humic. I’ll be seeding and fertilizing in the near future, but I do want to give the yard a little time to recover so I’ll probably wait a few days to a week to do that. Not everyone recommends seeding in the spring, but our bare patches definitely need it. I probably need to get some peat moss to mix with the seed. Although it probably sounds like I’ve gone all 4H (when I was in school it was all farm kids, I’m probably showing my age), but I really just want a nice green lawn that I can maintain. I don’t want to spend a great deal of additional time keeping it in shape. Hopefully some well timed interventions will get it ready for summer.

In other developments, I got my second COVID vaccination last Wednesday, and the side effects were slightly worse, I suppose. The arm soreness was about the same, but I think I felt some more systemic effects this time. It’s a bit hard to tell because the day of the vaccination I also ran (a modified attempt at resumption that was triggered by the broken elliptical) and scalped the lawn. Scalping the lawn (and bagging the clippings) is something that’s useful to do 1-2 times per year based on the advice I’ve seen. It’s somewhat like de-thatching, I suppose. In my yard’s case, it takes considerably more effort to push the mower across high spots in the ground. All that to say, the additional fatigue I felt the day after was probably a combination of the vaccination and the physical efforts of the day before. I also woke up around midnight feeling febrile, but didn’t bother checking my temperature. I just took a gram of Tylenol every six hours for the first day or so and things slowly got better. As I’ve said, eminently better than getting sick with COVID.

Things at work are going well. I’ve worked in the new location the last two weekends, and it’s a nice setting. Essentially the same drive as before with the last two miles being on surface streets. VES has been keeping me gainfully scheduled, one weekend at a time. My no-show rate has dropped a bit, down to only 15% of the last two weekends. I’ve been averaging about $2500 per weekend, which is okay. I’ve been hoping to maintain closer to $3K per weekend, for a monthly total of $12K. Based on how they’ve been filling my schedule (partially) and the no-show rate, I’m not sure that’s achievable with only a two day workweek. At least it’s adequate for our financial goals of paying the house off slightly faster and maintaining a discretionary income. I only want to work enough for those two criteria, as I really value my free time.

Back to homefront matters, Aeyong is recovering fairly well. She had her cast removed the week before last, and she’s jumped back in to her normal routine. Maybe a bit too hard because she’s got some wrist swelling today and will need to rest a bit. She’s been catching up on several things she wanted to accomplish including trimming and bathing all the girls. She also has been out in the yard working, and this weekend she decided to help me out by dusting and cleaning the bathrooms upstairs. That was a nice surprise because it had been nagging me for several weeks and I had been too busy with regular work and work around the house. Still, she’s probably paying for the uptick in activity right now.

I’ve been trying to improve the garage layout the last few weeks to coincide with efforts in the yard. I installed some overhead storage shelves and moved the treadmill and elliptical all the way back against the wall. Not a huge change, but the added floor space has been nice. We took the vertical shelves that were previously on the back wall and moved them into the laundry room, giving us some more storage space in there. We had a little half shelf in the laundry room before, and now that has moved to the garage as a rolling storage cart for our air compressor and shop vac. I’ll eventually install another identical set of overhead shelves in the other garage slot and hopefully free up another section of the floor. Eventually I want to have a rolling workbench with some good working tools - table saw, miter saw, router, and maybe a few other tools depending on how things develop. I’m going to try to ease into woodworking, but I already have all sorts of ideas for projects. I don’t know if it’s just a natural part of aging, or a genetic thing I get from my father. He was definitely a DIYer at his core. Nature, nurture, or perhaps a bit of both?

After all this fairly mundane material, I haven’t stopped pursuing my core disciplines, although there have been more days “off” when I was working at VES or had my time manhandled by DIY, medical, etc. issues. I finished a Premiere Pro course, and I’ve just started a Photoshop course. I also signed up for a basic piano course, mostly to cover some fundamentals that I know I’ve been lacking. I’ve really only slowly learned songs and then just spent my time practicing them, but I haven’t spent any considerable time at learning scales, improvisation and some of the basic skill set I need if I want to advance further. The same could be said for my other disciplines as well. I’m alternating my drumming practice between Mike Michalkow’s course and trying to learn Xanadu for the eventual Rush AFTK deep dive video. Check back next year, probably. Then there’s also bass, guitar, singing, drawing, writing, learning to speak/read/write Korean. Not to mention maintaining my CMEs for work. The days are just packed, and that’s how I like it.

It's been one of those months...

I feel like I was thinking that through most of 2020, and 2021 is not showing any signs of let up. In 2020 there were times where days and weeks would seem to run together, but then there were many times that every day was a new reason the world was about to end. 2021 hasn’t been quite that severe, and by most metrics things are looking up, but February would prove to be a tremendously tumultuous month. Yes, I alliterated tumultuous. Gird yourself for more.

The weekend of February 13-14th would see me braving the oncoming winter storm to work on Saturday, but even by then I knew Sunday was going to be sketchy. I was already calling VES support to cancel my clinic for Sunday as I drove in for the Saturday clinic. Ironically, there would be multiple reasons why that was unnecessary because VES would ultimately decide to close down themselves as the severity of the winter storm developed. Even more importantly, I would be taking Aeyong to the emergency room. In a fit of youthful energy for the novelty of snow, she ventured out front, slid down the driveway (about two feet by my recollection); her feet went up and her right wrist came down. Hard.

The result was a displaced, angulated, comminuted, intra-articular fracture of her right radius. Hurts just saying it. We managed to get her into a nearby ER (thanks to USMD for actually being open when most places were closed), got her fracture partially reduced and splinted, and got her enough pain killers to tide her over until she could get seen by orthopedics, which would end up being nine days later. I cancelled my upcoming VES schedule for several weeks so I could tend to her needs while she recovered.

Thank Snowmageddon ‘21 and Texas’ feeble ability to cope for shutting down almost everything for a week. Not that we should complain too vociferously. All of our essential utilities remained functioning and by current accounts the only significant damage we incurred was a sprinkler system pipe and several plants and shrubs. Thanks to a frozen spigot, a neighbor sustained enough water damage that there were still reclamation trucks out in front of her house as of yesterday. I guess she had to hit the reset button on her ground floor.

The rest of February and early March was a challenging period of time. Aeyong underwent surgery on February 24th, and Dr. Niacaris was all we could have hoped for in an orthopedic surgeon. She has some extra hardware in the form of a plate and six screws, and it’s possible she may eventually need to get the plate removed as it was designed for bones larger than her relatively diminutive frame. She had her first post-op last week and things went well. She was gifted a new cast in sexy purple, although she’s been finding it a bit less comfortable than the splint she had before.

She was judged as lacking in her rehab milestones and I got a stern glance from Dr. Niacaris. She only responds so much to encouragement, so I try my best but it’s leading a horse to water doncha know. I went back to work at VES last weekend and things are going alright. I have one more weekend starting tomorrow, and then I’ll get yet another weekend off as they relocate to the new facility a few miles down the road in the Las Colinas area. As the crow flies it should be closer to home, but there are additional surface streets in the route, so based on google map’s prediction, it’s basically a wash in travel time compared to the current location.

Still, TXDot is adding lanes on the G-Dub, so it’s possible I might decide to switch to a weekday schedule in the future. With a slightly shorter drive and more lanes for traffic, it might not make as big a difference working weekends versus weekdays. While things progress with VES, things are finally about to completely shut down with the North Texas VA. I got a few text messages from Dr Hasan asking about my last workday, but when I asked what it was about, all he would say was “we’re trying to determine when fee basis last worked here”. Yeah, I gathered as much. When I got his message notification, I briefly felt optimistic, but clearly there’s no plan on bringing fee basis back at this point. To sort of bookend that interaction, I got an email from the VA remote access manager stating my authorization was about to expire. I wasn’t thinking about it, but I guess my access was approved the same day fee basis was laid off, 3/24/20.

So, it’s essentially been a year since me and my fellow fee basis examiners were laid off. What followed was in some ways a challenging year although we fared so much better than many people. The biggest frustration for us was being out of work and losing about 3/4ths of our income. It would be nine months later before I would return to income producing work with VES in December. After a few months, things seem to have stabilized. The treasury has helped restore our pre-pandemic checking balance thanks to a big refund as well as stimulus payments. I finally had the confidence to shift some more money to our mortgage payment, so we’ve gone from the minimum payment to one that will see the house paid off in three years. I might increase it yet again depending on our ability to continue running budget surpluses each month. This is contingent on a steady supply of exams from VES.

For giggles I checked with my former colleague, Dr C, who is working for QTC, to find out their current payment rates. I’m not sure if he gave me his rates or the PA rates, but they’re even less than VES. If they’re his MD rates, I can only imagine what they’re paying PAs. As I’ve said here before, it’s my strong feeling that VES is lowballing their payments to providers, but this is anecdotal based on what I previously received as a fee basis. There may be truth to their statements that they are having exams combined into one rate as the number of DBQs increases. Dr Brooks is still waiting on his FOIA request. My feeling is that it will reveal nothing or it won’t reveal enough to really discern whether VES is inappropriately paying their examiners.

One other positive development is that I was able to get my first of two COVID-19 vaccinations on Wednesday. I had signed up with Dallas County and I got a text message on Monday offering the shot. I took the first available appointment time on Wednesday and it was held at a joint Grand Prairie/Irving mass vaccination site being run at the Theatre at Grand Prairie. I was impressed with the efficiency and relative painlessness of the operation. The main side effect of the vaccination was pain at the injection site which was worst yesterday, the day after the shot. Today that pain has reduced substantially and I’m not really feeling any additional side effects. We’ve been told the second shot is worse for side effects, so I’ll see. It’s still exponentially better than getting COVID and potentially dying or suffering long term health effects from it.

'Supdates

After a tumultuous week in the aftermath of Aeyong’s injury, we finally got into to see her pcm and had the referral submitted right then. The office visit with the orthopedic surgeon was approved by the time we got in our car, and we went and saw him yesterday. We had to go to Harris Hospital in Ft Worth, where I had my right knee surgery back in ‘81ish. I’m not sure how old Harris is, but it’s pretty long in the tooth. As we tried to find our destination, we engaged in some of our age old raving and drooling as we negotiated the turns and twists that every hospital complex seems to build into its infrastructure.

The actual entrance to the Ben Hogan facility (I think it’s mostly sports medicine/ortho) was in a loading dock, I think selected for COVID flow control. We were checked in quickly and everyone rolled pretty smoothly. They shot new x-rays and gave her a new fiberglass splint that’s going to have a shelf life of less than 36 hours methinks. Her surgery was put on the schedule for the next day (today) and we’re heading over to check in at 0630.

Dr. Niacaris seemed nice and professional. He is planning on using a plate to stabilize her fracture and thinks it’s possible she’ll need the plate removed in four to six months, since it’s a little large for her wrist size. He’s not sure, but stated the possibility was higher given that her frame is small. All the medical treatment parts of this process have been pretty good. The USMD ER visit went about as well as it could - they got her in quick, managed her pain, got her sedated and partially reduced, and then got it adequately stabilized for her to get through the week until seen by ortho.

The ortho clinic itself went well - we didn’t wait long to get in and there was no part of the process where we were kept waiting very long for them to complete all their tasks. Interestingly, there was no real pre-op other than the x-rays. I think it’s a function of COVID now that she is getting all her pre-op labs done the morning of the procedure. I assume they want to minimize the number of hospital visits.

It’s a same-day surgery, so hopefully everything will go well and we’ll be back home this afternoon. I assume her pain will be worse for a few days, but hopefully she can start healing properly and I also hope she won’t need an additional surgery a few months down the line.

Progress never waits and I had my first IMO (independent medical opinion) from VES this morning. It’s a case from last month that I had seen, and I was surprised they presented it this way because it means they actually have to pay me for it. When I checked into my VES portal, I also saw they had added a patient for March 13th. I hadn’t told them to resume my schedule, but I think I must have mentioned that weekend as my likely return. That actually works with what I’ve been thinking, so I told them to resume scheduling. This will give us a few more free weekends to get her through the initial recovery stage.

Regardless, I’m only out of the house for about 8 hours on two days, so she should be able to attend to whatever she needs while I’m out. We’ve been engaging in a bit of nail biting and hair pulling while sweating out our Tricare approvals, but so far they’ve gone through okay. We paid our co-pay for the surgery and the lady in billing stated we had $54 left in our deductible. I’m still not sure what that means, because I can’t seen anything in our Tricare self-service portal that reflects that amount.

Outpatient surgeries are supposed to have a $63 deductible, so it’s not immediately clear to me why it’s slightly reduced. We have a catastrophic cap and point of service limit, but our information indicates there’s still plenty of room within those. All that said, the estimated cost of the surgery is $63,000 and we’re paying $54 so far, so it’s completely acceptable. I think that’s just an estimate for typical procedures like hers, we’ll know the actual costs after the fact. We’re very thankful to have good health insurance, we know there are many underinsured or non-insured people who would be financially devastated by an event like this.

Winter Whimperland

Continuing the running commentary del whinage, it’s been one of those weeks. A massive cold front has spread across most of the continental U.S., and when I say most, I mean like 98% or so (based on my highly scientific glance at a map on a weather site). With the cold came snow and ice, and in a fit of wintry novelty, I coaxed Aeyong into coming outside to check out the lovely white expanse.

Bad choice. In an uncharacteristic spree of high spirits, Aeyong decided to ski down the driveway and made it about a foot before disaster set in. I think she only made it to the first e of “Whee!” before her feet were launched skyward. Gravity is a harsh mistress and wasn’t offering any soft landings on the frozen driveway. I thought she landed directly on her tailbone, but it was her right wrist that bore most of the force of impact. And, in a contest between bone and frozen concrete, the latter almost always wins.

She sustained a comminuted, intra-articular, angulated and displaced distal radius fracture. In medical terms, we refer to that as “F&*# Me!” As I told her, she wasn’t fucking around. This is her first broken bone in her life as far as she remembers. If you wait until your mid-fifties to break your first bone, you should do it in style, you know the old saying. We both have now sustained orthopedic surgery inducing fractures, just in case anyone thinks we don’t go full throttle when the time is at hand.

The irony is that the rare cold front with snow/ice included that caused the injury in the first place has also shutdown most of our infrastructure, making medical follow up all the more complicated. We were fortunate enough to be able to get her all-wheel drive Toyota out and make it to the nearest ER in Arlington. We’ve subsequently learned that just another few blocks down the street is a Level II trauma center, which would have been the preferable place to go. Lesson learned. Although I’m still practicing medicine in the fringes of disability, local hospital and medical center infrastructure hasn’t been something I’ve investigated very thoroughly. I always kind of tangentially knew there was a medical center/hospital with an ER right there on the highway and down the street from our PCM, so that was always the default ER location we’d attempt first if it was beyond an acute/urgent care type visit.

Now we know to go a little further down the street if it’s trauma or more likely to require the services of a specialist. We don’t routinely need to avail ourselves of medical care in general (not counting prescription refills which are mostly remotely automated), so these aren’t issues we have a great deal of experience with in the recent past.

To add insult to extremity trauma, the infrastructure shutdown has carried across all sectors, so we couldn’t reach anyone to arrange follow up yesterday. I left messages on our primary care doctor’s site and the ER doctor had recommended several orthopedic surgeons, most of whom wouldn’t accept our insurance. Thankfully, one of them was part of our PCMs group and does accept our insurance. Their appointments department called me at the end of the day yesterday, and we’re in the process of coordinating a follow up appointment not with that doctor, but with the groups hand/wrist specialist.

Hopefully the doctor and his clinic will be open for business and we’ll be able to navigate the streets across town. The temperature hasn’t risen above freezing for a few days and that’s going to last a few more days before it slowly starts crawling back upwards. Right now it’s a sweltering 1°, and that’s Fahrenheit. But hey, no wind to speak of! We’ve had at least one set of pipes freeze for an upstairs bathroom sink that’s on the outside wall. Once I noticed, I went around and set all the other sinks to drip, but this one doesn’t seem to be budging. I really hope we don’t get burst pipes out of this, just to add onto all the other fun.

Because of the need for me to look after Aeyong, I requested VES to cancel all of my upcoming schedule until we get a better idea of her upcoming treatment schedule. Surgery will be a definite necessity and then there will likely be a great deal of physical therapy in her future. Hopefully most of that will be during the week, so I’ll eventually be able to return to work, but I imagine it’ll be several weeks before we’re on the other side of things.

I’m sure I’ve expressed my religious beliefs (lack of) here before, but I do like some of the wisdom found in tomes spiritual. “God laughs while you’re making plans.” This could also be expressed as “Life is what happens while you’re making plans.” We’ve had a year chock full of life happening in direct defiance of all our plans and expectations. COVID-19, layoff and eventual termination of my work with the VA, all the nail biting and teeth gnashing related to the state of politics and governance in this country, etc.

It’s not all bad, though. As I’ve said before, we’re among the fortunate in that we have a steady retirement income, a good home, and we haven’t truly suffered any deprivation this whole time. This injury has been the most devastating medical event in several years time, and it will be rough going for Aeyong for weeks and months to come, but we’re both still standing and we’ll come out this intact I’m sure.

The urge to dip into our retirement savings has reared it’s ugly head yet again, especially considering the prospect of not wanting to work for several weeks and wanting to maintain a positive cash flow. We’re not at a point that we need to make that decision just yet, though. Financially, this should hopefully just be a temporary setback while we get Aeyong healed and I can eventually get back to work and get some cash flow restored.

Laid off

I got the news via email (at 3 AM, which is nice) that Fee-Basis are being laid off by Ambulatory Care/C&P for the next 2-3 months or until C&P resumes normal operations. They are suspending any in-person exam requests and our outgoing program analyst (Curray) said he wasn’t sure they would have enough work for the FTEs (full-time equivalent) as well. While I can’t disagree with the logic, it came a bit faster and harsher than expected.

We’d already been game-planning the possibility, so it doesn’t come as a complete shock, but again, it was a bit sudden. Right now I’m trying to decide how I’m going to approach this. I sent out a feeler to Holly Gallegos (fellow Fee Basis and VES examiner) to see if she had an updated point of contact with VES. I have a feeling they are going to be scaling back if not suspending operations as well because I assume conducting exams would open them up to some liability issues. I’m curious if VBA is triggering the change to what they call ACE (acceptable clinical evidence), meaning exams and opinions that can be conducted remotely. That may be the case. This means that there’s probably going to be a huge backlog again in the future when the VA resumes normal operations.

I’m not sure, but it’s possible we can survive on my pension income alone, so we’ll just ride the storm out for as long as needed. We’ll have a better idea in the next couple of months about what’s happening with our cash flow. I’m debating about resuming a full-time schedule with Berklee, but I honestly would rather change my major to dual Guitar/Music Production before taking any more classes. I’ve got to decide on an audition and just submit it. Ironically, I’ve been laying off the guitar for several days with the COVID doldrums, so this may be the spark I need to get my playing back into shape. I hope my elbows are on board for this as well.

This was always the big risk/worst-case scenario when I decided to switch to Fee-Basis three years ago. I can’t really complain because I’ve been able to earn an additional three year’s salary above what I would have earned as an FTE, not to mention I’ve been working three days a week at most. It’s a strange feeling to think I’m not going to be scheduled to work anywhere for the indefinite future. COVID-19 is proving to be this generation’s single greatest cultural, economic, historical, etc. event. The world is already significantly different and I don’t see things ever going back to where they were before.

I’m glad we had paid so much down on the house, although the argument could be made that a bigger emergency fund would have served us better in the short term. We crossed under $100K a few payments ago, so switching to the minimum payment will stretch out our payoff date to six years, down from our plan of one year. We have a decent checking balance at present, so I’ll just watch what happens to our balance over the next few months. Given our normal monthly necessary (emphasis on necessary) expenditures, we may break even or even accrue income.

I’ve started canceling all the non-essential subscriptions, mainly to some music programs like Steven Slate and East-West Composer Cloud. I may leave others as-is for now, just to see what happens with our bank balances. We shouldn’t need to cut off any vital services like phone, internet, television. We should have enough money to cover those as well as groceries. We do have to think about those big financial outlays like the various insurance bills - medical, home/auto. We should be able to cover those, but they are big single time expenditures different than monthly maintenance.

I think there may be some silver linings to these clouds, although difficult to see at present.