Archive for the 'bureaucracies' Category

New Year’s resolution 2015

March 15, 2015

I didn’t think about New Year’s resolutions when the calendar turned this year because I was so busy with my mother and her affairs.  But now that she is gone and buried and her affairs are at a point where they take up less room, at least temporarily, on my plate, the question of what I want to work on this year came to my attention.

I decided I want to work on my defensiveness.  I know it gets in my way.  It gets in other people’s way, too, I think.

My next thought was a memory of Willy sitting in an office with someone who was supposed to help our family, about whom I had my doubts and suspicions.  And there he was, sitting on the couch in her office, leaning back and with his arms so undefensively crossed above his head, his torso exposed (beneath shirt, tie, and jacket), talking so genially.

I can’t say how effective his attitude was in that situation, and I know it was not self-consciously produced.  But he was offering no resistance, and that, I am pretty sure, can be a good thing in some situations in which I unhelpfully introduce my baggage of fear about what may come next.  The thing I want to try doing is staying in the actual moment and worrying less about where it will lead.  I don’t mean suspending my practical judgment and not making a photocopy of an important document before I send it out, but I think there is a point of balance that I have overshot; perhaps I have learned to overshoot it, but we can unlearn survival skills that got us through one situation that are now getting in our way.

So that’s, I think, going to be my approach, to try to stay in the moment, discern what I am called on to do without so much concern about what comes next, what sort of a limb I might be going out on or what trouble might ensue from the other end (will the office process my paperwork correctly and how can I, in how I prepare it, guard against it doing it incorrectly, for example) — I want to try to wait to see, to wait and see, and not get all tensed up about it.  I want to put my best foot forward instead of arranging it according to what I think may come next.

I got a sense of what that would feel like both when Willy died and when my mother died — it was as if I got a preview of how I could be, and I have to say, it felt great.  It wasn’t irresponsibility but something like allowing everything to take its appropriate place.  Having gotten that preview, I have to figure out a way, I think, of how to develop organically to get from where I am to that place — the sensation and attitude did not stick.

I think this may apply to personal relationships as well as to business contexts.

We’ll see.  At the very least, I am hoping that I feel lighter, that I feel less regret that I have contributed unnecessarily to the creation of vexed interactions with others.  I am pretty good at figuring out what I want to do in other ways so that I have least regret, but I think I have not yet addressed how my defensiveness can produce difficulties in that regard.

In some ways I think it’s a question of editing out that aspect in my presentation of myself to others — I doubt I will have no concerns about what will happen next — but in other ways I think it’s about “turning things over” more — I tend not to turn over my love life or my bureaucratic life enough, I think.  That would be about feeling less of the concern that produces the defensiveness in the first place.  If I give more space for the universe to work in those situations in my life, I am hoping I will feel greater peace, the sort of sensation I got a preview of when my loved ones died in my presence.

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Personal Representative

March 6, 2015

I have to say that I liked the term “Executor” better.  It’s shorter, too.  (I shied away from Executrix, when I was administering my father’s Estate, because it sounded too precise in a language that doesn’t usually distinguish gender, although I did have a friend who wanted to call female professors “Professoressa.”)

Anyway, in Massachusetts, we are called Personal Representatives, that’s what’s on my Letters Testamentary I just received in connection with my mother’s Estate, and the lawyer who sent me the Letters advised me in no uncertain terms to use that term when I asked her about it.

I guess Personal Representative seems to me like such a broad and nebulous category, even if it actually isn’t.  It reminds me of personal care assistants, it reminds me of other sorts of representatives.  But I have to say it makes a little sense to me in the context of this being my mother’s Estate.

Shortly after my mother died, I was making a call notifying my father’s employer’s benefits department of my mother’s death, and I easily gave them her Social Security Number off the top of my head when they asked for it, I had had to use it so often on her behalf for so long.  Then the customer service representative asked me mine.  I actually had to stop and think.  My mental compartment for reeling off an SSN was now filled by my mother’s, not my own.  (I can do Willy’s, too, but I do that with a kind of mnemonic device.)  I had to remember the different cadence I use with my own, and that helped me back into being able to toss it off.  But it was a little weird to remember my mother’s SSN better than my own.

I really had come to represent her.

Bus cards

December 21, 2014

I gripe about technology, I admit it.  Here’s a recent occurrence.

I got on the bus yesterday, first time in a long time, and one of the automated messages during the ride was that some of the “Charlie Card” fare cards are expiring and we should go to a T station with fare machines (none are in my town) to see if ours is such a one.

They may have said it was due to a software upgrade, but I am not sure.

We checked online when I got home and found further information about what to do if we end up with inaccessible stored value on a fare card — go to Downtown Crossing (in Boston) to get that addressed.

I would have preferred one fare for all, paid in cash, all along, to having to do this, especially since it comes at an especially inopportune time for me.  I assume it is something of a monkey wrench for some portion of other passengers, too.  If we don’t take the steps outlined, and our card is one of those expiring (which I am thinking is likely mine is, because it’s pretty old, but let me add, I had no idea that if the card were to expire, there wouldn’t be an easy transition), not only will I lose my money on it, but I will pay higher fares going forward if I don’t obtain a new card.

My gripe is that the system is sold to us on the basis of convenience and pricing, but we actually pay up later, with either greater inconvenience, or worse pricing.

Reminds me of the behavior of private telecommunications service provider companies — they make an arrangement with the customer, induce some amount of reliance, and then unilaterally change the arrangements to the customer’s detriment.  The pattern teaches mistrust, it seems to me.

When I first got on the bus, I was thinking about whether I should put more money on my card.  Interesting that I may well end up paying the pay-as-I-go higher, cash fare instead.

What it takes away from me is the sense that I had in my wallet a card I could rely on in a pinch to get me a ride on the bus, that I had made adequate preparations.  That was a false sense of security, it turns out, perhaps because I didn’t pay enough attention to the details of the card arrangements, I don’t know.  I am sure there is a lesson in it.  It certainly echoes other patterns for me, involving my being taken in by what turns out to be salesmanship.  I wonder if technological innovation lends itself to that pattern.

When the bureaucratic tail tries to wag the medical dog

December 12, 2014

A bed could not be found for my mother at the case manager’s first choice for a nursing/rehabilitation facility, this Friday afternoon, and she suggested maybe they should just send my mother home instead and have her hire some services.

I did not take to this idea well.

Long story short, my mother will be discharged tomorrow to a bed at a different facility.

I knew from many perspectives that the attempt to change the discharge plan from rehab to home made no sense.  The medical team hadn’t changed their conclusion that my mother needs to regain her strength and mobility and such before she goes home.  The kind of services a patient can hire, especially on short notice, would not provide the type of care and therapies for improvement needed at this point.  On a weekend, there is even less access to supervisory help, and often the people who work weekends are new hires, so it would be even less likely the work offered by the in-home services would be adequate.  The out-patient specialist had told us that the rehab center would be familiar in their own right with the symptoms that need management, even without her instructions and prescriptions — in other words, the specialist was relying on my mother’s being discharged to a rehab center.

In addition, I did not take well to the idea that I would be the person on the spot to take up the slack, should the hired services be as inadequate to the situation as I expected them to be based on my prior experience with other ill family members.

I also made the point that without adequate discharge plans, my mother would ricochet back into the hospital.

As I said, the case manager abandoned her home discharge idea and found a bed at another rehab center.  All’s well that end’s well, but I was appalled at the process.  Having been around this block before, I knew enough to object and to be able to object effectively, but I was not a happy camper.  The hospitalist I spoke to later assured me my mother would never have been let out the hospital door with a discharge plan for home like this, that she (the in-hospital doctor) would never have approved the plan, and so newbie patient families are not put at risk of being taken in by and agreeing to this kind of case management behavior.

But it is unnecessary aggravation, in my opinion.

I can see that my challenge was to speak up and advocate on my mother’s behalf but keep an even keel.  I think I am getting better at it with all the practice I am (unfortunately) getting.

And I got nice phone calls this evening from the social worker on my mother’s team and from the hospitalist, after I got home.  They said they would provide feedback to the case manager.  That sort of resolution and such support are far better than what I’ve experienced in the past.

 

 

 

Medical procrastination

December 10, 2014

My mother’s lab tests came back and a specialist appeared in her hospital room — and told her, when she asked whether he would now be in charge of her care, no, that will have to wait for the out-patient clinicians to be brought on board.

Really.

Now the campaign begins to have enough of a treatment plan in the discharge instructions, when that time comes, to tide her over until she is actually seen by the out-patient clinicians.  We would like to avoid another re-admission to the hospital.

It would be farce if it weren’t about what it’s about.

I bought my mother an electric menorah this evening.  I don’t know what connection that has with all this (she had mentioned she wanted one for her apartment, instead of her usual candled one), except maybe it expresses hope in the midst of dystopia.

The power of money and corporations

July 18, 2014

I had to send three tax waiver certificates from the New Jersey Division of Taxation to a brokerage firm office in N.J.  I’m up in Massachusetts.  I sent them by overnight express mail from the Post Office (and I used the street address for the firm, not a Post Office Box).  That service claims it guarantees delivery the next day by noon.

I didn’t need the speed of express mail as much as I wanted the tracking, and I also wanted the documents to spend as little time in transit as possible, to minimize the opportunity for their getting lost.

So I expected the item to show up on the tracking as having been delivered by noon the next day.

Well, it didn’t and it wasn’t.  But what really surprised (and frustrated) me was that the USPS thinks this is okay.  Their claim is that it’s all up to the brokerage firm;  the firm has paid the Post Office a handsome fee to pick up its mail at the Post Office at will, as many times a day as it wishes to send a runner.  Apparently this means that the USPS does not deliver to the firm’s door, even overnight express mail.

So my piece of mail arrived at the Post Office on the day following my mailing of it, at 10:44 a.m.  It was “available for pick up” at that time, and, apparently, that fulfilled the Post Office’s duty on this delivery, from their point of view.  Didn’t matter that that wasn’t my arrangement with them, they allow this corporate arrangement to mean that the firm can decline to pick up the mail until they decide they want to.  Of course, the particular recipient of the mail could probably have requisitioned a pick-up by noon if they had wanted to — they did receive a call that the item was there at the Post Office, although I am not sure exactly when — certainly by early afternoon.  As it turned out, the item was picked up the day after the guaranteed-by-noon day, at 8:00 a.m., and this wasn’t posted on the tracking until the day after that.

Next time I may try UPS.

I am surprised that the arrangement with this corporation was allowed to trump my control over how I wanted the mailed item delivered.  I thought that in many situations, people and institutions depend on the delivery mechanism, and timing, being as advertized at the point of purchase.  Instead, it looks as if the Post Office has outsourced this decision to the recipient corporation, if they are willing to pay.  With all this technology, I might have thought the clerk at the counter where I mailed the item could have been alerted to the fact that this service would not be implemented as advertized, for this recipient.  In any event, there needs to be better communication.  (There also needs to be better handling — one of the clerks at the receiving Post Office told me that the item had been flung onto the counter and no one could figure out what to do with it for some time.)

I’m glad the tax waiver certificates arrived, and I hope to be able to distribute the remainder of the account to my mother today, to close the account for my father’s Estate, and to, for all intents and purposes, have finished administering my dad’s Estate.

Diana from Arlington

April 26, 2014

I was sitting in a lobby this morning, about 30 miles from home, waiting for a bureaucracy to grind its way through some paperwork, and I realized that the woman sitting near me was similarly waiting for the same process to be completed.  So we started chatting, and sharing how we came to be there, and in addition to having in common some details which were somewhat predictable, it turned out that her name is also Diana and she also lives in Arlington.

Whose brother or sister?

February 23, 2014

“’This isn’t the drug user of the 1970s. It’s your brother, your sister. It crosses all socioeconomic strata.’”

This is a quotation from “Max Sandusky, prevention and screening director for the AIDS Support Group of Cape Cod” and it comes from an article in The Boston Globe called “Opiates taking heavy toll on Cape,” by Brian MacQuarrie, dated February 22, 2014.

Years ago when a child in one of our sons’ nursery school class died from strep, and a few months later our son came down with scarlet fever, just two days after having been examined by his pediatrician, someone important in the public health sector in the state government told my husband that nothing would likely be done about what was going on in the nursery school until the child of somebody important died.

It was pretty clear that someone in the school was a carrier — there were many strep cases at the school in addition to Jillian’s and our son’s — but no testing could be undertaken, nor could the staff member who seemed to be the carrier be asked to take steps to protect the children.  As I recall it, she had a connection to the health sector, perhaps through a second job, and the hypothesis was that she picked up bacteria at the facility but didn’t become ill from them.  And if it wasn’t she, then some sort of testing of everybody might have revealed a different pathway through which there was such an on-going and severe presence of strep in the school, even after vacation breaks.

In other words, it wasn’t just a single event during which children passed strep germs to each other;  and the public health official knew that.

We withdrew our child and found a new school for the fall.

There’s that set of lines from Richard Shindell’s song “Transit” about how “car thieves and crack dealers, mobsters and murderers [are someone’s] husbands and sons, fathers and brothers.”

When we are still picking and choosing whose lives are more and less important, we cannot yet congratulate ourselves on being “superior.”  It’s a paradox, resolved, it seems to me, by withdrawing the ego and no longer seeing the world in terms of competing groups.  We become “superior” (in the sense of “more elevated,” not in the sense of comparative elevation to others) by realizing that we are not.

We may pay more attention to an important public health problem now that more “important” people’s lives are involved, but we will not be resolving a more fundamental problem, and its manifestations in our society, until we stop with this “four legs good, two legs better” (Animal Farm, by George Orwell) attitude.

More on accountable care organizations

December 17, 2013

So the Accountable Care Organization returned my call, and pretty promptly at that.  What was explained to me did not make a whole lot of sense, but maybe if I try to explain it, it will make more sense.

While the letter was pretty general about Medicare sharing information from other providers with this provider (the primary care doctor), which made it sound to me like coordination of care and case management, what the person at the ACO told me was that only information from providers who are members of the ACO is shared (with other members of the ACO).  So I asked why route the information through Medicare, why not have the member provider just share the info with the ACO directly?

One answer seemed to be that the information that the provider gives to Medicare may capture different issues, issues that may have gotten left out of the medical records themselves.  (No, putting it into an electronic format does not improve its accuracy or completeness, garbage in, garbage out, and all that.)  It seems that the ACO is providing oversight of the doctor, reminding them of preventive care that is indicated by the billing codes;  to provide a more independent check on the doctor, the information that is used is not reported directly by the doctor to the ACO.

Why the patient isn’t just asked to consent to the doctor sharing information with a supervisor is not clear to me.  I see that the way the written explanation of the sharing is structured would allow for the possibility of Medicare sharing any information they have, including from providers not members of the ACO.  The person I spoke to said they aren’t doing that.  I would say what she said and what the letter said are not completely congruent, and that if the arrangement is not about coordination of care and case management, then I’m not really sure what improvements in efficiency and outcomes they expect.  It sounds as if some of the purpose of this plan may just be to pick up the slack for care doctors’ offices no longer provide, like following up to determine whether there is compliance with care instructions and medication regimens, or following up to see if there is a need for support in order to do those things.

So it sounded as if this is about providing supports to doctors — reminding them of indicated preventive care and providing follow-up with patients.  Apparently doctors’ offices are not themselves positioned or structured to do that.  But adding this intermediate layer, including routing the information through Medicare, sounds expensive to me.  I guess it’s just the cost of doing business when human beings organize themselves into groups with the social and financial incentives we have.

If the ACOs develop into something more robust and effective, then I think we run into the issue of where a patient’s information will end up — then a tiny leak in one place, including in the course of transmission, could mean a whole lot of private information being compromised.  As it is, adding more social workers and such into the mix, in order increase patient compliance, will mean more individuals having access to patient information, including, for example, having the information on laptops they carry into cars to make patient visits.  It will be interesting to see how that all works out.  Visiting nurses already do that, but I’m thinking that multiplying the number of people with access to information increases the likelihood of compromised situations and mistakes.

I think I thought that ACOs would be more like structures located within the offices of the doctors’ practice (not be a separate organization) that would provide checks and would streamline organizational practices, etc., and that the information about patients would not be transferred to new locations or to new organizations.  I guess I am concerned that, like the Affordable Care Act’s exchange website, nobody has really thought through how the whole system will work when all the pieces are put together.

Oh, those electronic medical records!

December 17, 2013

I was reviewing my level of distrust with a situation I will describe below, and concluded that I, too, have been impacted by the “If you like your policy, you can keep it.”

I have multiple family members with Medicare, and one of them received a notice that their primary care doctor is becoming part of an accountable care organization (ACO), I assume as a result of the Affordable Care Act (ACA).  The family member may opt out of having medical information shared around among their providers through Medicare and this ACO.

In the past, admittedly in a different context, one of these providers has made a point of only sharing the minimum of information necessary, as the provider has seen problems arise.

So the family member is thinking about opting out of sharing.  But we are concerned that this could mean the family member will be told by the primary care doctor that the doctor can no longer be the family member’s doctor.

The notification letter tells the recipient to call Medicare, I did, and they don’t know if that can be a consequence.  The number for the ACO gives only a voicemail option, so I dutifully left a message.  The other option is an appointment with the doctor — but we’re supposed to pay a co-pay, not to mention time, energy, and parking fees, to talk about this?  Doesn’t seem appropriate to me.

In any event, I file this under (a) the unintended consequences of storing medical records electronically, (b) distrust created by misleading promises in marketing the ACA, and (c) distrust of the medical bureaucracy in general.