I suppose it's a small, personal triumph, really.
Since August (2012), I have been battling a flare-up of Psoratic Arthritis.
While it is true that a common site for this type of arthritis is the hands, the neck (cervical spine) is the second favorite site on the list.
If you have a pain in the knee, for example, you can often sit down to give your knee(s) a break. Without both permenant and detrimental consequences, it's much more difficult to take the pressure off of your neck, if you know what I mean (only in literature and movies can a character survive with no head attached!)
Anywho, as I was growing up, because she simply didn't want to expend the time nor energy to deal with the matter at hand (and she still doesn't, as far as that is concerned), my mother would give me the 'brush off' by telling me that my extreme joint discomfort was 'growing pains.' You must know beforehand, dear reader, that my maximum adult height is 5'4". While I am reasonably intelligent enough to intrinsically know that "You should never try to teach a pig to sing. It will only waste your time, and annoy the pig!", contrary to popular belief, I am more optimistic than the average person in my SMALL inner circle would have you to believe. The eternal girl scout that is trapped inside my little gimpy body will never stop fighting to win the world over.
In response to my mother telling me that my pains are 'only growing pain', I would tell her "I know that the average person walking down the street doesn't feel the same pain that I am feeling. If that were the case, #1) the murder rate would be considerably higher, and #2) If these aches were 'growing pains', then I should be 8 feet tall! Since I am NOT 8 ft. tall, these are not 'growing pains'."
By professional license, I am a nurse. I have been an LPN since 1994.
My physical therapist has 6 yrs. of college under her young belt, and a year and a half of job experience. I told her the 'growing pains' story, and, also knowing my (lack of) good family history, she laughed and said, "There is no such thing as 'growing pains', and you are right - your pain has always been from both traumatic arthritis..." (my right foot is a different volume of books, in itself), and she continued with "The majority of your pain is most likely linked directly to Psoratic Arthritis.."
Even though a true and accurate diagnosis by professionals who are doing their jobs, rather than from mothers that could have done considerably better at their job (and I am truly being kind by 'leaving it at that'), this disclosure is not the victory at hand that I am celebrating.
Back to August 2012:
The next 2 paragraphs are a brief history, which may be skipped, if you so desire:
I am a Medicare patient, and I have chosen Essence Health Care as a Medicare replacement plan. Essence is available only to local St. Louis area residents. It costs me no more than the ordinary original Medicare Part B plan, and I get Part D (drugs / medication) free. Don't misunderstand me. I do have a tiered co-pay on my medications, but the addition of Part D, itself, is free with Essence.
Eight years ago, the truly wonderful Dr. Sandra Hoffman (Rheumatologist / Internist) x-rayed me from my neck to my toes. She said the psoriatic arthritis has affected many of my joints, and it - back in 2004 - it had already fused my neck, and that my back was getting bad, too.
Dr. Sandra wrote me a prescription for Celebrex (which was easily covered by the insurance that I had at that time. Remember, I had degenerative disease process (arthritis) 8 years ago. Degenerative diseases don't get better over time. They do what they say they do: They degenerate - they get worse!
In January, 2012, I was required by Essence to have a Dr.'s exam, and a 'wellness' visit. Considering that I am a nurse, and I have been a patient, for one reason or another, for my entire life, I REALLY do like to let as much time pass between visits to a Dr.'s office as possible. With those considerations, even though this was officially a 'Wellness', by the time I force myself to spend the time, the money and the frustration of going to a Dr's appointment, I positively have real and necessary reasons to see him.
Translated: Rather than paying him a co-pay to walk into a Dr's office and say, "Hey, how you doin'? My name is Michael J Keller. It's good to see you!" (Then walk out of the office), I am also in his office to receive treatment for a medical condition that has most likely been bugging me for days, weeks or usually - years.
This Dr's office was only 2 miles from my home. When I walked into the tiny waiting room, I noted that by at least 25 - 30 yrs, I was the youngest patient in the room. (I'm 44). Because...uh... I do not look an ordinary boring citizen AND I am not in in the average age bracket of a Social Security / Medicare patient, AND I was, by several decades, the youngest patient in the room, the proverbial red flag flew up in front of my face, and started flapping about furiously in the wind - so to speak.
A second warning light flickered on when I was taken back to an examination room by the nurse. This particular office also an Essence-provided Nurse Practitioner. This person served as a 'middleman' (middle woman, in this case), and as a link between the Dr's office, and Essence, itself.
This middleperson came in to the room and took my lengthy, gimpy medical history. Me - the patient - had to explain to her the definitions of both Erb's Palsy and Habba Syndrome (We're not even talking about my right foot. Again, another book for a different day.)
A few minutes after Miss Middleperson left the room, the Dr. came in to do his examination.
After he shook my hand and introduced himself, he happily and proudly exclaimed, "I hear you're our distinguished and honored guest today!"
I live in Ladue, MO, AND I know how I look when I am in public spaces:
99% of the time, my beard is ALWAYS in it's "up style", which requires occasional hair color, hair mousse, a comb, LOTS of hairspray, and considerable time using a carefully aimed hair dryer. I wearing either one of my hand knit hats or more likely than not, I am wearing the fantastic creation you see in the picture at the top of this blog. With a good amount of certainty I am relatively certain that this Steampunk / Western combo hat it the only one like it in the St. Louis area. I also wear a hand made choker made from heavy hardware (honestly - hardware from Home Depot. It has 72 welded nuts and bolts). Add the Adam Lambert-style heavy style black eyeliner and the 3/4" plugs in my ears, and you KNOW that I will never blend in with senior citizens in ANY Dr's office waiting room.
Cutting to the chase, and finishing this chapter of this storied saga:
This first Essence-supplied Dr. quickly wrote out a couple prescriptions. Neither of these prescriptions were covered by Essence, and I couldn't afford to pay full price for them from my own pocket, so I had to leave them unfilled, and to go on with my life without help in these areas.
After the "Glad To See You!" Dr. left the room, he said, "You're doing good! I'll see you in 6 months!"
The survivalist in me wanted to immediately scream out, "NO! WAIT! What do I have to do - or how do I have to look - to get you to believe that I am here because I NEED HELP, and it is *your* job to help me?" But, the realist that I am took over, and before I walked out of the office, I was determined to find a Dr. that could and would look past my exterior, and see a broken structure within those walls.
I as pointed in the direction of a gay-friendly doctor that knew that my exterior was a mere shell, beneath all my smoke and mirrors is an official gimp.
As much help as a Doctor can give in this day and age, this new doctor has helped me immensely.
He gave me a prescription for Lomotil, which allows me to leave the house without knowing where every bathroom is in every business we frequent. Habba Syndrome is an evil, ugly disease that is usually lumped under the catch-all category of "Irritable Bowel Syndrome" because the Dr. doesn't know what else to call it. IBS (if there really is such a disease!) and Habba Syndrome are very different diseases.
Essence Health Care requires that a patient be "stepped" to a more expensive drug before it is prescribed and issued.
For Psoratic Arthrits, I had been taking over 3,000 mg / day of over-the-counter NSAIDs. Taking this high amount will shoot holes through my liver and my stomach. However, pain is a fantastic motivator. When the doctor advised against taking this large amount of NSAIDs, I told him, "Hell! The damage can't hurt any worse than the severe debilitating migraines that are caused by the pain in my fricken cervical (neck) spine!"
He put me on Meloxicam, which is a slightly more potent drug than over-the-counter NDAIDS, and it is one pill instead of the 15 pills that I routinely take.
With most patients, Meloxicam will work if there are *NO* other factors in the situation: During cold, rainy days, for example, or a GOOD psoratic arthrits flare-up, I could pop a handful of M&Ms, and better results than the Meloxicam can give me. At a relatively early stage in the arthritic disease process, Meloxicam usually has to be upgraded to a more potent drug.
In September, 2012, I reached that point. I need to be upgraded to Celebrex, the drug that was originally approved by my earlier insurance (8 years ago), and one that I knew would help me.
Remember....Essence has the worthless 'step program'. I had fulfilled Essence's 'step' requirements by first taking over-the-counter drugs, then taking the Meloxicam. My pain level tells me that a prescription for Celebrex is long overdue.
Essence requires that the prescribing Doctor send an ACCURATELY FILLED OUT FORM verifying that the appropriate 'steps' have been taken before they will authorize a more expensive drug - Celebrex, in this case.
My Dr's office staff assured me that they would send the paperwork to Essence, and within a couple days, they should fill the prescription. I asked the very patient Peggy, my friendly pharmacist tech at Schnuck's Pharmacy (Lindbergh & Clayton Rds., St. Louis, MO) how long it should take for Essence to approve the Celebrex prescription. She advised me that it could take "from 2 days to 2 weeks."
Anybody that knows anything about me at all will tell vouch for the fact that I am not a patient person by any means. I did wait 8 days - over 1 week - before I called the pharmacy again. She told me that the prescription was still 'in progress', and that within a couple days, the Celebrex prescription should be approved and ready for me to pick up.
After the conversation with Peggy - the pharmacy - I received a call from my Dr.'s office. The office personnel that called me told me that "for unknown reasons, Essence out-right denied my Celebrex prescription, and that I should remain on over-the-counter medications (Yep! The ones that are punching holes through my organs!), and continue to take the now-ineffective Meloxicam, or call your rheumatologist for further help."
I did as I was advised: I called my rheumatologist, and she ordered another NSAID that was less expensive, and it was covered by Essence.
I had Mark pick up this new prescription on his way home from work.
(For reasons that will soon become apparent and clear, I am honestly overjoyed that the Celebrex prescription was in Essence's system *before* the drug (Relafen - generic: Nabumetone) that my rheumatologist ordered was into their system.
Since it was late in the day, and past normal office hours, I had a sleepless night. I was infuriated past the point of tears. Why would Essence deny a needed increase in my medication when they had proof that I had taken all the necessary 'steps'?
I had my shaking finger on the trigger, and I was chomping at the bit to blast the Hell out of the insurance company. BUT....while I defiantly do not want to yell at the WRONG person, I REALLY DO want to yell at the right person.
I decided to call Essence to get the whole truth for myself before I lit the fuse. I was so mad that I decided to wait a while before I made that call. I knew that I never regret anyting that I say, but I knew I could probably use more polite wording, even though the devil in me wanted me to rip them a new ass.
I got an honestly helpful representative from Essence on the phone. She looked over the details and said, "Sir, it looks like you haven't completed the 'step' program. That is why we denied the Celebrex prescription. I will check with another department to make sure that is correct, but I'm pretty sure that is the accurate reason you were denied."
At the end of her work day, the insurance rep called me back. She reiterated the fact that the proper steps had not been completed.
AH! I see the light clearly now! I knew the pharmacy had not 'dropped the ball', and now I knew that the fault was most likely not Essence's fault.
I never did get to the bottom of the deal, but I am almost certain that the Dr's office either:
1) Did not fill out the form AT ALL that explained that I did, in fact, do the necessary 'steps'
2) As often is the case, when the papers are faxed, 2 pages stick together, the second (stuck under the first) page doesn't get faxed, but in the end, because this stuck page is pulled through the fax machine', it is the 'faxed' stack, and he 'sender' has no idea or knowledge that this important, vital information has not, in fact, been faxed.
OR..... if the ball was, in fact, in Essence's court:
1) They misplaced the important 'step' information.
2) There was some unfortunate incident (read: mistake) when the information was entered into whatever system Essence might have.
Whether we have 6 of one thing, and half a dozen of the other is inconsequential. Either way, a mistake was made, and I had been waiting 2 weeks for a prescription that I desperately need that should have been filled in no more than 2 days from the day it was originally ordered.
SO....... I really did not want to yell at the WRONG person, but I really DO want to yell the RIGHT person - the individual responsible for messing up my prescription.
Two days ago, I left the physical therapist's office (after getting both physical therapy and dry needling (acupuncture). Before I walked out of this tall, mostly-medical building, I went to the 14th floor, which is the 'break area' for the entire building.
I needed to get my ducks in row before I started blasting people for screwing me over.
I called the Essence once more to see if they have, in fact, received the correct information from my Dr.'s office, and to determine the immediate status of my Celebrex prescription.
This time, the customer service rep at Essence was't as compassionate as the first rep that I called, and this lady wasn't willing to view the subject from a different point of view.
She told me, "Sir, you must complete the 'steps' before we can approve the Celebrex prescription. I see that you have been on over-the-counter medication and Meloxicam, but just yesterday, you got a prescription filled for Nabumetone. The Nabumetone IS a part of the'step' program, and you must give this drug a trial period before we can approve the Celebrex prescription."
I tried in much vain to explain to this lady that I was given the Nabumetone prescription to hold me over until the mistake that had been made with the Celebrex order had been cleared up. She wouldn't hear of it, and she didn't want to listen to me. I left the break room on the 14th floor of this building, and I took the elevator to the 1st floor. During the elevator ride to the ground floor, my cellphone started breaking up, and I eventually lost her signal (which was most likely a merciful gift from GOD!)
I never called her back.
By the time we reached this level, I was thoroughly pissed at this game. I was well 'over it'.
I thought, "What have I done to myself? Have I just shot myself in the foot by doing what my primary care doctor advised me to do?" (Before they realized that a mistake had been made, they called me and advised me to call my rheumatologist - which I did. God LOVE her! Dr. Barbara Caciolo, MD, came to my rescue. I saw her only days before, and she knew my psoriatic arthritis flaring up with a vengeance These days, it is a rare occurrence indeed, when a Dr. does his or her job, and they do it efficiently.
BUT....I thought I did damage to the situation because this new medication was ordered, and I would have to 'ride this one out' for a few weeks or months before I could get the Celebrex that I had been working so hard to get.
Within a half an hour of my call with the 'not-so-understanding' representative from Essence, I received a call from Schnuck's Pharmacy:
"Michael, your Celebrex order has been approved, and it is ready for you to pick up.!"
I don't know exactly who to - honestly - thank at Essence for finally 'seeing the light', and realizing that the Celebrex was ordered and was entered in their system before the Nabumetone had been ordered and entered. SOMEBODY knew the rules of the game, and they knew that they had to both consider and fill the order that had been placed FIRST (Celebrex) before they filled or considered the SECOND order (Nabumetone).
FINALLY! After fighting this mini-war since August, I get the medication that my aching bones need! Forget the aching bones....the muscle contractions that the arthritis in my neck have been causing brings on a blinding migraine headaches - every day.
I fought 'the system', and I won.
It is a small victory, however:
When I picked up my prescription, I noted on the paper and the receipt that only 30 pills were ordered, and the total $$ without insurance would have been a little over $200. "HUH?", I ask myself. I have taken Celebrex in the past, and I know that there should have been at least 120 pills in that bottle, and the pre-insurance total should have been between $550 - $800.
This is the clincher:
The order is:
"Take 1 capsule every day."
CRAP!
Remember, I am both a patient and a nurse. This is the TINIEST Celebrex prescription that I have ever seen! The order is for 1 pill a day. when I was on this medication *8* years ago, I was taking 4 pills a day. Do the Dr.s really believe that a degenerative disease is going to improve? Nope. No can do. Degenerative means just that: It gets worse, not better.
So....because the tiny amount of Celebrex that I DID receive will do me absolutely no good at all, and is, in fact, a huge laugh, I will take it with the Nabumetone for a month. The 2 together should bring my inflammation down to a small roar. THEN....I tell my Dr. that the 1 capsule is no longer effective. I will get 'bumped' up to a relatively NORMAL Celebrex prescription (2 to 4 capsules per day, minimum).
GEEZ! The work-arounds that have to be done to get where I need to go!
"Getting old is not for sissies!" True.
But....
"Being a Gimp isn't for sissies, either!"
It should be of no wonder to individuals when they see a crabby old person or a pissed off Gimp! It's hard to wade through the medical crap that we are forced to drudge through, and not get a little - or a lot - on us!
- Michael
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