Wednesday, May 10, 2006

Divided Loyalty: A Tale of Two Primary-care Doctors, VA and Private

"Should I or shouldn't I?"

That's the question millions of Medicare recipients are asking as the May 15 deadline closes in for signing up for the new Medicare prescription drug plan without a stiff lifetime late penalty.

With dozens of plans to choose from -- each with different formularies, premiums, coverage, and co-pays -- people are confused and afraid of making the wrong choice. Meanwhile, the clock ticks ...

Well, I'm not one of those lying awake at night racked with worry. I did a cost/benefit study of Medicare Part D and decided that, for me, the coverage stinks. On top of that, the out-of-pocket costs are outrageous (and sure to get worse), except for people who are very poor and who take lots of prescription drugs.

But I also have a back-up, and a good one: the VA. As a veteran, like the lucky veteran here being treated by a VA doctor, I have been going to the VA for many years. The VA offers veterans prescription drugs at a modest $7 co-pay (soon to rise, however), without a monthly premium and without the diabolical "donut hole" of Part D.

Desperate to get people to sign up for the plan, the Bush Administration has been trotting out people telling the camera how much they will save. Some will be saving money -- until they fall into the infamous donut hole in which all coverage ceases and starts again only after thousands of dollars more are paid out of pocket, in addition to the monthly premium.

Medicare Part D is a debacle and has been from inception. For most people the coverage is lousy, expensive, unreliable, and primarily serves the insurance companies and drug companies who all but wrote the bill. It is basically a complex system of subsidies to private insurance companies. And five of the biggest are in the process of helping themselves to about 80% of the gravy.

Paul Krugman of The New York Times summed up Part D's wrongheadedness: "Drug coverage could simply have been added to traditional Medicare. If the government had done that, everyone currently covered by Medicare would automatically have been enrolled in the drug benefit.

"Adding drug coverage would also have saved a lot of money, both by eliminating the cost of employing private insurance companies as middlemen and by allowing the government to negotiate lower drug prices. This would have made it possible to offer a better benefit at much less cost to taxpayers."

But before I passed on the Part D "benefit," I wanted to make sure that my VA prescription-drug benefits were a sure thing. I made an appointment with my VA primary care provider, Donna Santora(not her real name) a nurse practitioner, to discuss my VA drug benefits as a Medicare beneficiary. While I was at it, I would see about the reappearance of facial lesions.

I called on a Wednesday and got an appointment for the following Tuesday. Just like that. First, I asked about the facial lesions. "A couple of years ago, the dermatology clinic applied a new cream and the lesions went away, but now they're back," I said. "They're nothing to let go, so I think I need a dermatology appointment."

She drew closer and examined my face. "Yes, I can see. actinic keratosis. We'll get you a dermatology appointment." She wrote herself a note. "You'll get a notice."

Actinic keratoses is the most common sun-related growth. Those most at risk are fair-skinned, burn easily, and tan poorly. I'm not fair-skinned but my face burns after 15 minutes in the sun and never tans, though the rest of me does tan. The only place I get these lesions is on the face.

Though many people get these yearly and have them removed routinely, they are nothing to mess around with. If they break through the dermis, they can become invasive carcinomas which can metastasize and cause death. Definitely worth a trip to the doctor.

"Am I due for any tests?"

She went to the computer and pulled up my file. She viewed my past tests and tests due. "No, you're good. You're due for a sigmoid next year. I'll order all the physical exam blood tests. When do you see Dr. Marelli(not his real name)?"

He is my other primary care provider. It so happens that they both know each other well and cooperate in my care. In fact, for several years my VA nurse practitioner worked as a nurse with Dr. Marelli and he encouraged her to take additional training.

"I wouldn't be here without him," she says. "Also he's a great doctor, very thorough."

I go to Dr. Santora for ongoing preventive care, which is what the VA does best. I go to Dr. Marelli for what a private practice does best, which is the big stuff, such as when I needed two total knee replacements two years ago and when I was hospitalized last September with severe pelvis misalignment.

"I see Dr. Marelli on May 24th," I said. "Should I still go with the appointments so close?"

"Absolutely. We need to keep Dr. Marelli in the loop in case anything major comes up. If you get to the lab this week, you can bring the results to the appointment."

"I'll go tomorrow morning."


I had the blood drawn a couple of days ago. I walked in at 8 A.M. without an appointment and was out in twenty minutes. The results will go to my VA file and be mailed to me. I'll bring them to my appointment with Dr. Marelli on the 24th.

Next, I got down to what was really on my mind and the main reason I had asked for the unscheduled appointment. "You know this May 15 deadline for signing up for Medicare Part D is coming on Monday. I think it's a rip-off with awful coverage compared to what I get here at the VA. But before I let the deadline pass, I want to make sure I will continue to be able to get VA prescription drugs."

"Oh," she said, putting both hands to her face in real horror." I just went through that with my mother. It was so complicated choosing the best plan for her. And that donut hole! No coverage at all. I finally picked a plan without interrupted coverage but at a higher premium, fifty-six bucks a months. But don't you worry. Nothing changes for you. "

"What if I have to go to the hospital and need drugs there?"

"Dr. Marelli and I will talk. You'll get VA drugs. As a veteran, you have a right to VA drug benefits and between the two of us, we'll see that you get the drugs that you need. Don't worry about a thing."

I smiled.

I have twinges of guilt about seeing two primary-care doctors at the same time. In some ways, it feels like having an affair, even though both know about the other and do not not seem the least bit jealous. On the contrary, both are perfectly willing to share in my care and cooperate fully on an ongoing basis.

In a health-care system in dizzying flux, with patients routinely seeing new doctors all the time, the continuity of care offered by the VA is priceless. I have only recently begun seeing Dr. Santora (yes, I know she's not a doctor but a nurse practitioner but she does everything a doctor would do for me and more -- such as preventive care -- and I think she deserves the title.) But before I got her, I had the same VA doctor for seven years, Dr. Susan Krantz while also seeing Dr. Marelli.

Dr. Krantz is wonderful, caring, and dedicated. She looks you in the eye. She listens. While keeping a professional distance, always addressing me as "Mr.," she sees not just a patient but a person. She read my online novel, State Kid. She even called me at home to double-check on this medical detail or that. When she decided to leave the VA, and medicine, she called me at home to give me the news.

I was devastated. For months after she left in December 2004, I missed her terribly. I badly wanted to talk to her to tell her how I was doing and to hear about her new life. But of course I never tried to get in touch with her because I knew that both patient and doctor had to move on.

Nevertheless, I will never forget her. When the planes struck the twin towers on 9/11, I was in Dr. Krantz's office and we received the news together. We will be forever joined by that horrific event. Nor can I ever forget how this unspeakable event did not stop her from giving her full attention to my care. Remarkable.

What are the chances of my getting another Dr. Krantz at the VA? One would think not good. And yet, I have seen Dr. Santora about three times now and, honest to God, it looks like she is cut from the same dedicated and caring mold as Dr. Krantz. I think I have hit the primary-care provider jackpot twice in a row!

All the same, at a time when unequal access to health care is a major problem in this country, when millions of people have no health insurance at all – and often no health care except the emergency room – I feel selfish. Just because I was lucky enough to be eligible for the VA health care system and lucky enough to have private health insurance, I shouldn't be acting like a health care pig.

Yet ...

Dr. Daniel Marelli is also warm and attentive. He is a tall, young-looking man in his early forties with a friendly, easygoing manner, and laser eye contact. I have been going to him for nine years. He gives me annual exam at which time I brief him on my preventive care and tests from the VA. On anything serious, Dr. Marelli sees me on short notice, actually no notice.

He follows up each exam with a personal letter explaining the results, always ending the letter with something upbeat like, “I think this is a fine report and I hope you will feel good about it.”

Dr. Marelli comes into the examining room with paper files containing everything he has on me. The appointment usually lasts about twenty minutes. The wait in the examination room before the appointment is usually longer.

Unlike Dr. Santora at the VA, who has years and years of every little detail about me in her computer and can pull it all up instantly, Dr. Marelli must depend on his paper files, what I tell him, and what he can learn through his eye balls. The VA is light years ahead of private medicine in information technology, thanks to a top-to-bottom systems revamping over the past several years.

But Dr. Marelli is patient-centered, serious, and as Dr. Santora said, thorough. In the examination room, he listens more than he talks. During the annual examination, I lie on the examination table. He takes the blood pressure. He looks in the mouth. He listens to the heart, feels the neck and and presses on the lower abdomen.

“Feel any pain,” he asks. He checks the penis and testicles. “Any problems there?” he asks. He has me roll over on his side and does a rectal exam and tests the feces for blood. “No blood,” he says.

At the most recent physical, after Dr. Marelli had completed the exam, I asked which test is the most important. Without hesitation, he replied, “blood pressure and the rectal exam. Together they tell me more about the overall health of the body than anything else. If I could do only two things, I would do those two. By the way, your blood pressure is great, one-twenty over seventy.”

At every visit, I update him on my VA care and stress my wish to maintain my eligibility for VA medical care because of “all the uncertainly surrounding the health care system. You don't know what change you are going to be hit with next.”

“Absolutely,” Dr. Masserelli said. “It makes all the sense in the world for you to continue going to the VA. Fine with me. Go to the VA for certain things. Come here for certain things. Whatever works for you is what we do. I have no problem whatsoever. Who knows what's going to happen next in health care.”

He sighed deeply, shaking his head. “It's just awful,” he said. “People should not be able to get rich on health care. It's too important to too many people.”

He started to say more, but stopped himself, leaving me with the distinct feeling that this was just the peak of a mountain of displeasure.

So long and keep moving.


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