The clinic I work for as a contractor recently paid me, for my last pay period, an amount of money that was four times my typical earnings. Admittedly, how much I actually get paid fluctuates pretty wildly, but I figured I would have noticed having either 4x in arrears or having seen 4x as many patients as usual. But I'm paid via direct deposit, and the corresponding statement saying what I was getting paid for is put in my mail box at the clinic, so I had to wait till I was back in the clinic – today – to pick it up and find up why I was getting all this money.
The statement mystified me when I got it. It was two whole pages of pairs of canceled previous payments and replacement payments and at first I couldn't make heads or tails of it, and then I realized that I was looking at a statement where almost all the patient sessions listed had happened in 2016.
As I mentioned, last month, for the first time in decades, we got a raise. A big raise. Not big enough to be adequate, but big enough to be astounding. It was, we thought, effective starting May 1.
No. Turns out the raise was retroactive. To – apparently – Oct 1, 2016...
...The day after I posted the final sections of "Why You Can't Find A Therapist, No, Really".
Rumor has it that the raise – more properly, the increase in rate paid by at least two of the Medicaid providers – happened because MassHealth (Massachusetts Medicaid) leaned on them to do so, to fix the emergent strike.
MassHealth? Are... are you there? Are you reading my journal?
If so, thank you! (If not, still thank you!)
I have a few other suggestions for things you could fix!
For instance: I'm currently doing an amazing job (or so my chart reviewer wrote) doing care coordination with a big medical team involving four clinics, three hospitals, and family all involved in the care for a patient with an emergent psychotic illness. I can do that because the patient has MBHP, and MBHP pays for case coordination if it's extramural. I'd like to point out that it's insane that if I have a 15 minute conversation about the diagnostic formulation for a challenging and high-risk case with an in-house psychiatrist, I don't get paid for it (and neither do they), but if I do the same thing with a psychiatrist at a different clinic, I do. How wack is it that I literally wouldn't be able to afford to spend the sort of time on this case that I did (and continue to!) if the patient hadn't coincidentally decided he didn't like my clinic's available psychiatrist and went and found himself another one through his PCP. Surely this can't be the incentive system you want me or the patient (or the psychiatrist) to be functioning under – one where patients are incented to get their psychiatric care from an entirely different facility from their therapist.
And thank goodness that he had MBHP, as pretty much an amazing fluke. No other MassHealth payers pay for care coordination at all. If this guy had been on NHP or Tufts/BMC when he came down with schizophrenia... I shudder to think. Do you realize how much I've been on the phone with MGH's ER and APS and social workers and psychiatrists at local mental hospitals in the last six months?
Don't you think there should be some sort of provision for what happens when someone presents with a psychotic disorder? Like, when a provider slams the big red "R/o Schizophrenia" button, the payer has to start paying for some case coordination? (I'd also recommend that for substance abuse cases, where patients can manipulate providers around meds; and in mandated reporter cases, where you should probably have payers pay therapists for their time filling in DCF/DPPC/DES or whatever.)
I have to think that the time demands of handling such a high-risk case are part of why some – maybe many – therapist are leary of working with psychotic or other high-risk patients. I've been there. I've twice spent four hours – half a work day – keeping a patient in crisis calm and coordinating with the BEST team and then the hospital, and never saw a dime for any of it. Who wants to bring a patient onto their caseload, for whom the total compensation divided across the total hours of work for that one patient come to less than minimum wage?
And I'm just talking about care coordination – I'm not even talking about CPT 90839 and 90840 which last I checked were still universally unfunded. Funding that would be way cool.
I have many other fine suggestions – I swear many of them even aren't just suggestions you pay me more money! I'm happy to talk more about reforms in mental health care.
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I doubt he even remembers enraging me. But I almost screamed at him.
I’m still not sure whether it was his fault.
But let’s rewind. I have a friend who has pretty severe walking issues – he gets only so many steps in a day before he collapses. Most days he can get to nightfall without needing a walker – and he works hard, very hard, not to be seen as a burden.
More so, he struggles to be seen as a person. If you’ve never friended someone with a disability, you don’t quite understand how a visible handicap can eclipse someone’s personality. People tend to assume that everyone in a wheelchair acts the same – they talk a little louder, a little slower, they’re quicker to dismiss their opinions because really, do they know what they want?
Disabled people struggle to be seen. And my friend, well, he worked really hard to be more than his disability –
– which meant he pushed himself hard at conventions. Lots of covert sweating, casually leaning on bars, sitting down when they could. Because if he displayed weakness, the conversation would shift from all the happy things that made his life worthwhile and would focus on “Are you all right?” – which is a question he asks himself entirely too damn much as it is.
He wanted the con to be a vacation and not an explanation. Which was why his disability was, largely, not quite a secret among friends but something where the extent wasn’t entirely revealed unless you were in the know.
And my friend had held up well during the day but was starting to fade in the evening. He was looking for, well, let’s call him The Guy Ultimately I Wanted To Yell At, or Tguiwtya.
He was looking for Tguiwtya. Because he was good friends with Tguiwtya, and and wanted a few moments to hang with Tguiwtya to hang out before he collapsed. And my friend texted Tguiwtya to say “Hey, I’m on my way,” and Tguiwtya had said “I’m in the back of the ballroom.”
Tguiwtya was not in the back of the ballroom.
I ran into my friend, looking exhausted, who asked me if I’d seen Tguiwtya. I knew he’d walked all the way down from their room to meet Tguiwtya, exhausting the very last of his daily steps, and getting back up to the room would be an effort. I said I hadn’t.
He plopped into a chair, sweaty, miserable, waiting for Tguiwtya to show. I kept him company, brought him water. But Tguiwtya wasn’t responding to texts. And eventually, my friend said, “Well, let’s see if I can find him,” and staggered off, leaning heavily on his cane.
I wondered if he was going to make it.
I left. And lo, a couple of hallways down, there was Tguiwtya! Merrily laughing with a bunch of his friends. I collared him.
“Hey. Our friend’s walking the halls looking for you.”
He looked puzzled, as if unsure why I’d bring such a trivial thing to his attention. “Yeah,” he said. “That’s fine.”
I almost screamed.
What I wanted to yell was, “Do you fucking realize how much effort it takes for my friend to find you? You said your dumb ass would be at the back of the ballroom, and they exerted themselves to get to you because they like you, and now they’re straining themselves to find you again, and your answer should not be some pudding-faced ‘that’s fine’ but ‘Yes, sir, I will get right on that.'”
Then I saw Tguiwtya’s friends, crooking their necks at me.
Did I want to make a scene?
Was it worth looking like a fucking maniac in front of all these people, just to make a point about someone’s condition? Because they didn’t know. They couldn’t understand unless I literally barged into their conversation, twisted it, made it about this, and….
Shit, that’s gotta be what it’s like all the time, isn’t it?
Let’s be honest: Tguiwtya should have fucking known how much effort it took my friend to walk all the way down to meet him. I know for a fact that my buddy had talked to Tguiwtya about his illness. He was one of the inner circle, one of the folks who’d pushed a walker for my friend.
But how many times do you want to call some able-bodied person out for not comprehending something that they cannot experience? For Tguiwtya, “walking to the ballroom and back” was such a trivial effort that I doubt he even contemplated it as an effort.
Would I be damaging Tguiwtya’s friendship with my friend by explaining what an accidental asshole they were being?
That was, I realized, a brief window into being disabled. People don’t see your illness, even when you make it clear to them. They can’t comprehend that this background static of their lives could be a deafening uproar to anyone else.
And you always get to choose: make an embarrassing fuss and maybe get accommodated, maybe get rejected – or keep the peace and keep a friendship that means less but at least you get to keep it?
To this day, I’m still not sure if I should have yelled at him. Maybe I should. But he wasn’t my friend, and even if he was, I’m not sure I wanted to dress him down in front of a crowd of people.
What I do know is that I doubt Tguiwtya even ponders that moment. If he does, he thinks of me as the asshole who gave him a vicious side-eye when he didn’t break off his amusing anecdote to rush to meet our friend in the ballroom.
But I remember.
I learned something that day.
I hope I learned to listen.
Cross-posted from Ferrett's Real Blog.
No histrionics but somehow Rufus established himself as a cat Fig needs not to annoy, whereas Nigel is someone Fig will happily follow around.
Also, Fig made himself sick eating daisies, then tried to eat one again.
Jasmine's closets are filled with the late MV's comic collection. She's been trying to find home for the 30 cartons of comics for the last decade. If anyone would like them, they are free for the picking up (in bulk, not piece meal. Sorry.).
If she cannot find a taker in the next week, they are going out to recycling.
Please contact me here or at jdnicoll at panix dot com for more details.
Clarification: you can take individual boxes if you like. You just cannot take individual issues.