Month: December 2012

The ‘full bind’ story

Those who don’t know yoga may have been puzzled by my recent Facebook status update: “A full bind!” Those who know yoga and also know me may not have believed it. That’s OK – I didn’t either! I’m amazed at how far I have come in the last few years, fitness-wise.

This story goes back almost six years now. In my last few months at BNA I worked part-time, and I joined a health club not far from home. I got into a two-day-a-week routine and signed up with a personal trainer, Jen Young, and in short order I was back in physical therapy after stretching too far in the wrong direction trying to do a yoga pose she had showed me. It’s a twisting thing that gave me an incredible release, and I wanted to feel that again – so I tried on my own. Mistake. Not only was I a weakling and an idiot when it came to muscles and coordination, but I had no balance or flexibility. I could do aerobic exercise comfortably on a recumbent bike or a treadmill – that was about it.
After a few months of physical therapy, I was ready to train again, and Jen got me started with exercises the PT thought would be helpful. I also had a habit of rolling my foot to the outside and, sometimes, falling because of that. As a remedy, the therapist assigned exercises designed to strengthen my lower abdominal muscles and the quadriceps right above the knee cap. Jen took it from there, and within a few months I understood how various muscles worked and how to isolate them. Eventually I reached a plateau and decided to work out on my own until I was ready for more challenge.
I made progress on the weight machines and eventually switched to the ellipticals for aerobic exercise. These machines sat just outside the group fitness studio, where I saw a few friends – mostly younger than I was but including one woman my age. The first day I joined them, I fell off the resistance ball and bruised my tailbone! And, standing on one foot? No way that could happen.
My first class was Abs and Stretch, and I went to it twice a week. I learned that “core” didn’t mean the center of an apple. Eventually I was able to hold a plank for 45 seconds. And I never fell off the ball again.
The instructor, Judy Martini Abshire, taught an earlier class that included movement and weight-lifting. I started going into the studio in the middle of that class and found that I was getting a great aerobics work-out in there. Not being a particularly good dancer, I didn’t know what a “mamba” was, and being directionally challenged made things difficult for everyone around me when I went to the left while they went to the right. But after a time I extended my workouts to include all of both classes – an intensive two-hour session that I generally attended twice a week.
Somehow, Judy can teach a class of 45 people ranging in age from 12 to 80 and keep everyone working at his/her own level. The modifications she suggests for people with this weakness/injury or that present options that have helped me work on every part of my body. Over time I gained strength. I have increased my weights from 1s and 3s to 5s and 8s. I became a little more flexible. I stopped telling myself I couldn’t or shouldn’t try some of the exercises. And, I found that I could reach things more easily at home, pick up and carry heavy things, and generally take care of more things on my own. Needless to say, that feels good – and I don’t remember the last time I fell without tripping over something in the way.
After changing gyms in mid-2011, I also started working out almost every morning. My twice-a-week two-hour workout was no longer available, so I started trying other classes. The one that made a difference for me is called Yoga for Jocks. It’s not really what it says – I don’t think very many of the people in the class are athletes. But it is a very athletic class, without the spiritual focus that some yoga classes have. Instead, the focus is on breathing, strength, and flexibility. I have learned to stretch my muscles and, recently, have begun to improve my balance.
Now, about the full bind. I was, indeed, doing a side angle pose, and I was stretched beyond my imagination. My balance was good that day, and when Kelli said some of us should reach around and try it, I did. And, I did it!
Today it would not have happened – no balance at all. But I’ve promised myself I’ll try again. And someday, who knows? It might even happen again.

On religion

There’s an interesting article in yesterday’s Washington Post about how atheists talk with their children about terrible things like the Newtown shootings. It made me stop and think about my own beliefs – which, I think, are no different from those espoused by parents in the article. I touched on my “religious” practices in a post I wrote last week about why I did not attend the memorial service for a BNA colleague. In this post I’ll explore my own “religious beliefs” a little more.

First let me say, I identify myself as Jewish – no question about that. For many years Robert and I have been active in a small Jewish congregation in the Washington area, Kehila Chadasha – a “congregation without walls” that meets here and there, on a regular schedule, to celebrate holidays together and offer Jewish education for children and adults. We joined Kehila when our daughters were young to provide a more active Jewish environment in which they could learn the traditions we were raised with and become b’nai mitzvot if they wanted to. We’ve stayed active because Kehila is a close-knit community of families we feel close to and are comfortable with.
For me, at least, religion has nothing to do with it. I don’t believe in a “higher power,” with or without the miracles and unimaginable “explanations” for earthly phenomena (floods, tsunamis, spontaneous fires, plagues) that fill our history books, including the “holy” books. I’m not agnostic – I don’t question, I just don’t believe it. At Kehila’s services and holiday celebrations I’ve grown to love the music accompanying the prayers, which I sing because it feels good to join others in song. But I can’t bring myself to twist it all up into a “G-d” or force beyond “that’s just the way it is.”
And the food! Combining Robert’s family recipes with a few of mine, plus others we’ve explored from books and Kehila cooking demonstrations, we eat well – and, well, Jewish! Oh, we’ve embraced cooking from other cultures, and perhaps no holiday tops Thanksgiving for me with its lack of religious connotations – unless you consider our worship of food traditions on that day to be religious. But our year goes ‘round with the foods we love: plum cake for Rosh Hashanah, honey cake for Yom Kippur, homemade applesauce for Sukkot and with or without latkes at Chanukah, hamentashen not only at Purim but sweetening our lot all year … and a Passover table with too many traditions to mention in a blog post about something else.
So yes, I am certainly Jewish, food-wise. And I think (hope) we used the Jewish holidays and teachings well in raising our children to treat other people with respect and dignity. I think there’s something in there, too, about personal responsibility – owning up to their mistakes, striving to be the best people they can, and caring for others. Remembering and forgiving, themselves as well as others. Caring for and safeguarding the natural world. I think those are the main ones, for me at least. That probably qualifies me as more than just “raised Jewish,” as some others have chosen to say.
I’m not sure yet whether I think there’s a conflict between my personal brand of Judaism and being an atheist. Perhaps others would dispute that, saying that the belief in “one G-d” is fundamental to Judaism. But there’s also the perspective that I don’t worship idols and don’t believe in the Christian trinity, which the Jewish one-G-d declaration has countered for centuries.
So, there it is – at least as far as I’ve taken it so far. Perhaps there will be more on this subject in the future. Or perhaps, for me, that is enough.

Thinking of Cindy

I could not, for some reason, bring myself to go to a memorial service today for someone I worked with for nearly 30 years. Instead, I fell back on an “escape” from organized religion that I used quite often in my 20s – going to nature.

I’m not sure why I couldn’t go today. Perhaps it was that I wasn’t that close with Cindy. It would have been nice to see some of my BBNA folks, to let them know I share their sense of loss. But maybe that was my stubborn side’s point in not letting me go: if I want to see them, I should arrange it on my own and not take the opportunistic route. Someone’s memorial service is not, after all, a time to be social.
I don’t think it’s the cancer thing. At least, not Robert’s cancer – that nasty stuff still lurks in the back of my mind all the time, but I don’t let it get in the way. And, I know there’s no connection between Cindy’s death and Robert’s wellness. More likely, it would have something to do with all my BNA people who are no longer with us. I don’t even want to think back through the list – it’s too long, and it makes me too sad.
I think the real reason is the rituals I could not bring myself to go through. Not the Christian ones – I’m sure I would have been interested in the Presbyterian liturgy – I found myself surprisingly comforted by the pastor’s words at the Lutheran service when Susan died a couple of years ago. It’s more the social rituals – seeing the BNA people under these same circumstances, yet one more time. Acknowledging each other’s presence, shaking our heads in disbelief that another of our colleagues had died too soon, too young, with too much left to do in this world.
So, on from the maudlin: I took Chewey to Rock Creek Park instead.
I thought a lot about Cindy – her wit, her perception, her focus. I remembered all the times she patiently answered my questions at BNA shareholders’ meetings, keeping the focus on her duty as a director and corporate secretary to look out for the best interests of the company’s owners. I also remembered the times she brought humor into what otherwise could have been dull and dry meetings, making sure that we laughed and had fun even while we attended to serious business.
I can’t help but think she would have been pleased to be remembered in nature – a setting where I seldom saw her, but one in which I’m sure she felt at home. What could be more religious, more awe-inspiring than clear, crisp air and a vista showing Rock Creek and the hillside beyond?
So, this is for you, Cindy Bolbach. I hope you are smiling still.

More on the health care payment system

When it comes to paying for our medical care, I’m glad I’m not the one responsible for creating a reasonable system! But I do believe one needs to be created (see my last post), and I don’t think the health care law  known as PPACA (or the Affordable Care Act), having a single-payer system, or tweaking the free-market system we’ve been living with for years would do the job.

Here are some attributes I hope this new system would have:
·        There would be competition, and consumers would have a choice among providers.
·        Providers could set their own rates, on a service-by-service basis or in bundles.
·        The charge and payment systems would be transparent. Consumers would know what they are being billed for and how much it costs.
·        Providers would charge all patients the same rate for each service or bundle.
The free-market system, at least as currently administered, falls far short of these ideals, and it’s an easy target for me since it created the mess I wrote about Monday. There is competition, of sorts, and to some extent providers set their own rates. However, not everyone has choice among providers, and transparency in the current system is a joke. I don’t think very many people know ahead of time how much they will likely pay for medical services to be rendered. Under the current system, even services that are pre-approved by insurance companies often end up costing patients more than the co-pays we are required to put out in advance.
But a totally government-driven system doesn’t appeal to me. A single-payer system wouldn’t necessarily have to make all health care workers employees of the government, but it still would have to be supported by a huge bureaucracy. That would likely mean replacing the current inefficient mess, which saps at least 15% out of medical payments to support private systems, with a similar one embedded in the government that could end up costing even more. All health care consumers would be more vulnerable to the budget-cutting pressures we see threatening Medicare. Ultimately, it could slow the delivery of critical services to people in pain or in need, while they wait in line for capacity to be freed up to deal with their conditions.
So far, I think PPACA has the best shot at offering us some relief. If given a chance, it might actually bring enough people into the system to equalize some of the rate disparity caused by our commitment as a society to take care of people who don’t pay their share. New rules set to take effect next month will require providers to take steps toward cleaning up some of the mess that keeps them from receiving timely payments, steps aimed at improving the efficiency of the system.
It will only do that, however, if it forces health care providers into a more transparent set of forms and practices – one designed to provide actionable information and encourage consumers to pay their bills rather than set them aside until they have the time, strength, and stomach to wade through and figure out how much they really owe. 
That’s where this started on Monday, and that’s where I’ll leave it now. Feel free to comment. There’s plenty more to be said on this subject.

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Lamentations about the health care finance system

Something needs to be done about the medical billing mess! And no, I still don’t think a single-payer system is the only way to fix it.

It would be wrong to say that I “had to retire” just to free up enough time to deal with all the medical bills. But not spending time working does make it easier to “find time” to sort and sift through them to figure out what’s been paid and what needs to be paid. It should not be this hard. And, it doesn’t have to be.
In this post I’ll lay out what I think the problem is. I plan future posts on the subject to explore options for fixing it.
Here are some real examples from our records:

A melanoma specialist told us he sent biopsy slides to Boston University for another reading. A bill came from a laboratory, and another bill came from Boston University. The dates for these services don’t match each other or match up with any of our appointment dates. The explanations of benefits from the insurance company that appear to match up have different names from the ones on the bills.

A service had to be pre-approved, and we were asked to pay the copay of $392 on the day of service. Then we received another bill for $30.31, with no explanation of why it was more.

We received a bill dated 8/23 and paid it 9/12. The bank said the payment cleared 9/19 but the payment wasn’t reflected on the statement dated 10/8. The statement said the bill was seriously past due. Seriously?

A surgery bill arrived from one hospital for services provided at another facility. (We are grateful that this bill wasn’t sent until after the insurance payment had been received. However, the bill said the account was past due.)

Matching up all the bills from the orthopedist with the superbills from the visits and the insurance payments reflected on the Explanations of Benefits (EOBs) was a nightmare. This was the first time in years that this physician’s office has filed directly with the insurance company. We didn’t know how much we would end up owing so we held off until we got the EOB. Then, his office began adding interest to our bill before the first insurance payment was made, so the numbers never matched up.

We went in for a post-surgical visit and paid the copay. We questioned the surgeon’s cursory statement that the melanoma team at the hospital thought we should follow a “watchful waiting” regimen. Eventually the oncologist came in and explained their thinking. We were billed for a second copay because we saw both the surgeon and the oncologist.

We received a bill from a laboratory in L.A. with “address service” requested to an address in Cleveland. We haven’t been to L.A. in years and didn’t know any services had been provided there. We presume this had something to do with the slides sent to Stanford but no proof. We had already paid Stanford for the services we thought they provided. Aetna paid the bulk of the charges, so we paid the bill … 
I could have weeded some of those examples out – but the cumulative effect is part of the problem. When you have a pile of bills, all in different formats, with statement date and service date in different places on each one – and not always standing out from the clutter of other “stuff” on the bill – it’s pretty easy to think you are caught up in a conspiracy designed to make you lose your mind. It’s almost enough to make me rethink my opposition to a single-payer system …
Almost, but not quite! I also have two positive experiences to report. The first is our recent “transactions” with Johns Hopkins, which had the potential to be just as messy on the billing side as some of the ones I’ve recounted above. We’ve seen two doctors and had services provided by a number of departments at Hopkins, including CT scan and MRI. We paid copays when services were rendered at the Green Spring facility and never saw another bill from them after the insurance company paid. We’ve been to the hospital outpatient department and Cancer Center three times. So far, we’ve received a consolidated bill for the October visit showing all the services, all the insurance payments, and a total due. It’s broken down by provider and date of service, with services listed separately, insurance payments credited against each charge and a subtotal due to each provider. It allows us to pay the small amounts remaining in a single payment of the total amount due. It will be paid quickly because Hopkins offers a 10% discount if it’s paid within 30 days.
The second positive experience followed my visit to my physician for bronchitis, the first doctor visit I’ve had since I went on Medicare. Remembering what it was like when I sorted and sifted through all the bills that came for my mother-in-law, I was dreading this. But I’m pleased to report that my fears were unfounded – Medicare paid its share, and before I even got an EOB, I discovered that my Medigap policy had paid the balance.
This makes me look forward to Robert’s Medicare initiation on March 1. I’m glad to be leaving this FUBAR system behind!
I’ll think about this some more and do some serious research before I write about this subject again. Perhaps I can make my thoughts come together in some serious reflections. It’s worth a try – anything is!

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GVAX Cycle 2

Our trips to Johns Hopkins for the melanoma GVAX vaccine trial have almost become routine now that we are half-way through the trial – two injection visits done and two to go. But I did have another indication yesterday that our efforts to fight off another attack of this dreadful disease are only just beginning.

Thankfully, there was no drama associated with this visit. Our study nurse, Susan, had Robert lie down while the phlebotomy nurse drew all the blood samples – a procedure that made him pass out before the first injections on November 8. This time the precaution was unnecessary as this time there was no similar reaction. And, his blood pressure stayed within the “normal” range at about 135/84 – numbers that are high for Robert but nowhere near the dangerous level that they reached last month.
We met with Dr. Lipson next, and he did a very thorough exam – particularly, palpating every lymph node Robert has left and examining every inch of his skin. He asked about the history of a few “spots,” and that led me to bring up a subject that had been on my mind ever since our meeting with the dermatologist a few weeks ago. As I told Dr. Lipson, I had two concerns after that visit:

First, I asked the dermatologist to show me any spots he was concerned about and help me learn how to recognize abnormalities of concern. As he carried out his exam, he pretty much ignored that request and froze a few spots without showing them to me first.

Then, he said that Robert should have skin exams every four months. When I pointed out that Dr. Lipson had suggested a three-month frequency for the skin observations, the dermatologist repeated that HE felt four-month intervals are all that’s needed.
Dr. Lipson asked why I had the reaction I did – was it because of the advice the derm gave, or because of his manner in giving it? I think Dr. Lipson wanted me to consider an aspect of our health care choices that some people might not give much thought to: how much confidence would I have in this physician going forward? If I had confidence in this man’s skill as a dermatologist, would I be able to  “forgive and forget,” and be content if Robert continues under his care?
It’s a hard circumstance for me to be in. I certainly felt that this doctor gave Robert all the attention he needed during the November visit and thoroughly examined his skin. He communicated well with both of us even though he tacitly declined my request for a teaching session. All in all, I have no reason to doubt his skill and proficiency. Further, I have no reason to believe that there was any deficiency on this doctor’s part that caused Robert’s melanoma to go undiagnosed for so long – if there’s blame to place, it’s with Robert and me. Some of the top melanoma experts in this country have discussed Robert’s case with us in detail and have not indicated that they thought any signs of melanoma went unaddressed in his previous medical care. Melanoma sometimes presents like a cyst and sometimes doesn’t show up on the skin. I don’t believe there were indications of melanoma that any of Robert’s physicians did not recognize.
Dr. Lipson told us, as we already were aware, that Robert is a likely candidate for a recurrence of melanoma, having had the first one. He wasn’t talking about a recurrence at the same site, though he said that’s certainly possible – his concern was about a primary cutaneous melanoma cropping up at another site and growing very quickly. He explained, as has Dr. Sharfman on our two visits with him, that this period (in the first few years) is the one in which new primary sites are most likely to occur, and that’s why most melanoma specialists suggest skin screenings every three months during that period. And so, even if we have confidence in the dermatologist Robert’s been seeing – which we have no reason not to – the education I’m seeking is a good idea. He suggested that we see Dr. Tim Wang, a Hopkins dermatologist who has “made it his mission to educate patients” about what to look for on their own skin. Dr. Lipson said it might not be necessary to see Dr. Wang every three months – another dermatologist at Hopkins could take on that care if we decide not to go back to the guy we’ve been seeing.
It’s not my decision to make, and if Robert decides to continue with the current dermatologist I’ll figure out how to deal with that. But in any case, I do want the education from Dr. Wang and will try to get that arranged for our February dermatologist visit.
Cycle 2 injections
The second set of injections of the GVAX vaccine went pretty smoothly. Both Dr. Lipson and Susan told us that we should expect Robert to have a somewhat more vigorous reaction to these shots – more redness, swelling, and itching. Susan explained that now that the vaccine has been introduced into Robert’s body, his immune system should be on the look-out for it. When the newly injected cells meet up with cells in his immune system, they “have a party” and that causes swelling, itching, and redness. I hope it’s more akin to having a fight than a party – that’s what immune cells are supposed to do. But in any case, the reaction may be more intense this time.
Robert’s reaction when he received the injections was about the same as last month. At the sites on his thighs closer to the groin, he didn’t feel very much as the vaccine went in but did feel a little burning after a while. The injections at the lowest sites, closest to his knees, caused a burning sensation as they were given. This may be because there is more flesh on the upper thighs – just a guess, but it seems like a logical one. Susan explained to us last month that the syringes don’t have exactly the same amount of vaccine (what’s important is that the total amount injected be the same each month), and she uses the higher doses at the higher sites. As far as I can tell, this is all theoretical – the theory being that the fleshier upper-thigh area would be able to handle the higher doses. It seems to work out that way – the upper sites don’t burn when going in but get bigger reactions in the long run.
Susan also noticed the other reaction that repeated this time. After a few of the injections had been completed, she commented that Robert’s breath was beginning to smell like garlic. She explained that this is because of the dimethyl sulfoxide (DMSO) used as a preservative in making the vaccine. DMSO is made by oxidizing  dimethyl sulfide, a by-product of the wood-pulping process known as “krafting.” It’s been used as an industrial solvent for more than 60 years and in medical treatments for 50 years because it is known to penetrate the skin without damaging the tissue. When it is used as a vehicle for topical administration of anti-inflammatories, a known side effect is the development of a garlic taste in the patient’s mouth. Susan has noted “garlic breath” in other patients to whom she has administered the melanoma GVAX vaccine.
So far, that’s the most excitement we have to report for cycle 2. All in all, not a troublesome day.
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