In brief: The new era of medical care in which my docs can try out treatments, see me to follow-up, reevaluate, and adjust treatment plans because one time through that cycle isn’t automatically $90-$150 before the meds/braces/supplies.
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The whole notion of a “co-pay” has always offended my senses.
Over the nearly fifteen years I have paid out of pocket for health insurance, the co-pay always felt like I was proving to my insurance overlords that I was “doing my share” by contributing something to the medical care costs. I was already paying $100-$200/month (even as a healthy 20-something), but they needed me to toss in $30 for my annual, $30-50 for visits to the nurse practitioner with a UTI, $30-50 for follow-ups for abnormal PAP results, and $15-25 for the occasional sinus infection. Then there were the co-pays within the co-pays: $25 for tests done at my annual, $60 for the lab processing at my UTI appointment, $90 to have the HIV test as part of the routine STI protocol.
When you have to front that kind of money on your way through the doctor’s door, you don’t go to the doctor very often even with “comprehensive” insurance. Factor in the knowledge that you’re leaving with a script requiring anywhere from a $5-$200 co-pay at the pharmacy, and you really debate before picking up the phone to seek medical care. Will going to the doctor mean skipping your phone bill or not eating the last week of the month? Which is more harmful to your body: waiting it out to hope it heals itself and being able to eat, or skipping a few meals to afford the meds?
Even people with insurance make decisions like this every day. I had to make them for years. January was bananas-level expensive every year because I’d have to fill all my monthly prescriptions before meeting my deductible. My birth control wasn’t covered until the Affordable Care Act (please see my pragmatic love letter to the ACA: ”In the Tank For Obamacare! (10/15/13)”) and one of my generic — GENERIC — meds was $250 the first refill of the year. This meant that as a late 20-something without any chronic, pre-existing or otherwise on-the-record conditions, I shelled out around $650 in January. As a bartending dog walker, this was the slowest time of the year and also right on the heels of the holidays and just before tax season (independent contractors, even with good accountants, can pay out a month or two’s income on April 15th).
Co-pays also affect how doctors manage your care; no one is more familiar with how insurance companies ration resources and what they routinely disallow than your doctor and their team of billing personnel. I have had doctors tell me they’d prefer to write a script for a specific antibiotic, but they know “cost is a factor” for me. So they go with the second or third best and cross their fingers I don’t have a recurrence. (Don’t get me started on how this contributes to antibiotic-resistent strains of bacteria and the increasingly limited options we have as a species for treating routine infections.) Returning to the doc a second time for the same thing, often feels like this:
Now that I am a bonafide ZIP code lottery winner, my doctors and I aren’t limited by insurmountable co-pays.
“That’ll be a $3.00 co-pay, please.”
I have heard that sentence a dozen times already and I can’t get over it.
My physical therapist — who’s treating years of abuse to my hands, wrists, and forearms from college, writing, and intense, physical service industry jobs — has an extensive, long-term treatment plan for me. I am working up to doing the exercises five times a day (I can’t currently work my muscles and tax my nerves that much and still be able to write or pick up my nieces) and we fashioned a splint to wear at night so my left wrist is in a healing position. I go twice a week to update my doc and have him test how reactive my nerves are — an almost depressingly high rate of reactivity thus far. We add posture exercises to loosen my neck and shoulder muscles to take strain off my hands/arms/wrists (also working up to five times a day) and reevaluate discomfort level and effectiveness. He does heat treatments and works out the muscles in my forearms that I’ve had since tennis as a kid which are apparently taking up more space than their allowed and putting strain on the nerves that run through my wrists and hands.
I hurt when I get home — like I’ve spent too much time at the gym only working out from the elbow down. I can’t write (as you may have noticed from the lengthy gap since my last entry), but have to see this as part of building my long-term career. Typing is central to my process as I compose inside my head differently than when I speak out loud; I fear a day where speak —> type software becomes a necessary writing tool. Hopefully my ADHD will be under control by then and changes won’t be so devastating to the haphazard way my brain creates and composes. More on that later….
“Alright. Keep doing what you’re doing; work up to the full sets of exercises as you’re able to. This isn’t going to be fixed overnight, so come back after your trip next week and let’s see about adding more steps to the at-home work.”
“That’ll be a $3.00 co-pay, please.”
I gladly hand her my PayPal debit card; a sister has supportively sent me some money so I could afford this month’s round of co-pays and get my contract work done at a cafe by my PT’s before this appointment. I had come straight from my psych eval and hadn’t had time to go home or eat anything since leaving the house at 8am. My family-by-choice is simply the best.
The psych eval went really well! Hooray!
I have been waiting for help in this area for 25 years. Twenty-Five Years. I’m not “better” now; I’m just getting started — thanks to the $3.00 co-pay.
I have several issues/disorders that need treatment. If I had a typical $50 co-pay, my psychiatrist would be limited in options and we’d have had to rush the eval and go over all the possible outcomes and plans in one sitting because follow-up would need to be done in short phone calls. Fuck that. It took us the hour to go through my history, make preliminary diagnoses (made easier because I’ve been in therapy a couple months with a great doc), and draw up an initial plan.
I have dysthymia which isn’t directly interfering with my daily life (I have developed coping mechanisms), but goes back to my pre-teen years when it was very, very severe. I was glad to have the correct wording to describe a feeling that has come and gone over the years; in the past five to ten, it has been mostly temporary or situational.
The Mayo Clinic describes it this way:
Dysthymia (dis-THIE-me-uh) is a mild but long-term (chronic) form of depression. Symptoms usually last for at least two years, and often for much longer than that. Dysthymia interferes with your ability to function and enjoy life.
With dysthymia, you may lose interest in normal daily activities, feel hopeless, lack productivity, and have low self-esteem and an overall feeling of inadequacy. People with dysthymia are often thought of as being overly critical, constantly complaining and incapable of having fun.
That’s pretty much my middle school, high school, college, and early 20’s.
We went over the misdiagnosis encouraged by my mother when I was 23: bipolar disorder. With a more skilled clinician than the overworked, exhausted, frustrated doc at my sliding scale community clinic, bipolar disorder was quickly ruled out. My current psychiatrist is a delightful, late 30’s woman with almost stereotypically understated mannerisms often attributed to people of Asian descent. She had been calm and soft-spoken with the “mmmm” and “ahhh” and “uh hmm” mental health professionals use when listening to patients — until I mentioned the misdiagnosis.
“No, no…” with a hand waving and a head shake. “WHY did you think you were bipolar?”
This was going to be hard to explain without a lot of time. “My mom…”
She put her hand up again and nodded. “Ah.” Sigh. “Did you have the mania? Describe the ‘up’ times? Were you euphoric, or were these just breaks in the ‘down’ times?”
I smiled. It was really nice to have such solid communication and, frankly, to just be believed by a doctor so quickly. “I was never euphoric. I didn’t have to sleep much, but that was typical because of my school and work schedule. I didn’t want to take over the world or scale my building or go on a $5,000 shopping spree or muse over visions of grandeur.”
“Understood. The ‘ups’ were very likely just breaks in the very, very long ‘down’ periods and felt pretty good considering how awful it had been. That’s not the same thing; I’m glad you were able to get that misdiagnosis set aside. We have a word for what you felt long-term; for now, let’s move on to the ADHD…”
As we did the eval for ADHD (which I will certainly routinely shorten to ADD because pronouncing ADHD is much harder for me though they have dropped the distinction between ADD and ADHD), I began to realize why so many things have been so hard for me despite how capable I feel. I am like an 8.5/10 on the severity scale. I’m pretty much off-the-charts, how-are-you-doing-life level ADHD.
“Your IQ helped compensate for a long time. But it’s adding to your anxiety trying to control and mitigate the ADHD.”
Yes. Exactly. This is what my doc (shorthand for my therapist) and I both think. The anxiety is there, the low-grade dysthymia is there. Both of those are real, but very likely getting a handle on the ADHD will lessen the impact of the dysthymia and vastly reduce the anxiety. We may end up medicating more than just the ADHD, but initially it’s important to start with the most debilitating issue before throwing more than one kind of drug at an already complex chemical situation. Basically, I’m a science experiment for the next several months.
Now. Lemme tell ya something about Adderall.
We had to skip over the Ritalin because some people experience an emotional let down as it wears off and I am a prime candidate for that side effect. Which leaves me with the four-hour, fast-acting concentration drug. Today was the first day I could take a 10mg dose and since I’m having to lay off the coffee (that’s actually a goal as I’m a 10+ cup/day drinker and THAT IS EXPENSIVE and also inconvenient, not to mention extremely unhealthy) and I’m fighting off the pack of viruses working their way through my house, it’s hard to tell how much I like it. I still have a pretty solid headache from clenching my jaw; the pain from this much dental work lingers when you aggravate it.
Even with all the factors and all the incremental steps and all the reevaluations and knowing that I’m probably going to end up on Not Adderall eventually, I am feeling optimistic for the first time about my long-term health and well-being. My doctor prescribed the Adderall first even though we both think I’m going to want something that I don’t have to keep taking on an up and down, in and out of focus roller coaster for the rest of forever. I need a full day’s focus to work and even after that, I would prefer to enjoy the occasional hours of my day that aren’t devoted to work. (Especially now that I’m dating someone who demands in a loving way that I take a break here and there; he’s right, of course.) So why did we bother with the Adderall instead of going straight to the meds we both think I’ll like? Insurance.
Typically, insurance companies like it when you’re on cheap generics, not the fancy schmancy new “designer” drugs with the better effectiveness and fewer side effects and name-brand prices. She knows it’ll be easier to get my prescription covered in full without hassle if we do this first. And it’s not a bad double check on the diagnosis. There’s no way I’m not ADHD, but we can see what happens to me on a stimulant that isn’t long acting in case of side effects. I can taper my coffee intake and spend the next month playing with dosages, seeing if meds trigger underlying issues or worsen my anxiety.
It’s a good plan. We get to do this because I don’t have a $50 co-pay and my insurance covers the visits 100%. We can put together a treatment plan, give it a try, reevaluate, and adjust. And that sentence doesn’t come with a $150 price tag. It comes with a $9 price tag. And a $3 prescription.
So that’s where I’m at. Multiple therapies underway. Beginning stages for both. It feels good to have multiple conditions identified and my feelings, frustrations, and pain validated. We live in a SUCK IT UP culture and so I have. I took pride in how little sleep I got, how much I could deal with, how little I needed, how able I was to disregard basic care and work sick, tired and hungry.
Fuck all of that. I want to be well.
This post is an entry in my year-long project documenting all the messiness and inconvenience and stigma of trying to get well in our culture. You can subscribe, follow, and join in the journey at #GetWell2015 here and on Twitter.