How to Treat Plantar Fasciitis at Home

This is not my usual type of subject for this blog, but so many people need the information, I’m including it here as well as at my business site, http://elenelistens.com.

I often see patients complaining of heel and sole of foot pain. They may identify it as plantar fasciitis, or they may simply point to the spot that hurts. Most of them have shown the classic pattern, in which they have the most pain on first stepping out of bed in the morning, then feel better for a while, then have more pain again after being on their feet for a long time through the day. So many people have this pain going on that I want to get the word out more generally about how to relieve it, instead of just telling my own patients one at a time.

This common condition usually responds well to self-care, which is crucial whether one is working with a health-care professional or not. Let’s look at what’s going on in the leg and foot and what you can do about it.

The term plantar fasciitis refers to inflammation of the fascia, the connective tissue, in the sole of the foot. (Plantar means anything having to do with the sole of the foot, as in plantar warts, often mismentioned as “planter’s warts.”) Very often, the pain is felt mainly or entirely in the center of the heel. There is a simple reason for this. The Achilles tendon connects with the foot right there, and when the tendon is tight, it pulls on its attachment to the bone, which hurts, sometimes quite a lot. This can affect one or both feet.

Generally speaking, although the pain can feel like you’ve got a rock in your shoe or like there’s a sharp object inside your heel itself, this is not necessarily being caused by a heel spur, which is a growth of extra bone on the calcaneus (heel bone). Heel spurs often cause no symptoms at all, and may or may not exist at the same time as plantar fasciitis. If you do have a heel spur, don’t panic. The usual treatment is the same as what I am describing here, and it is very unlikely that you will need surgery or any kind of drastic intervention.

Why is the pain worse first thing in the morning? During the night, your ankle extends, since you are not putting weight on your foot, and the back of your calf is allowed to shorten (as is the sole of your foot). As soon as you do put weight on the foot, your ankle must flex so that your foot is flat on the floor, which pulls on the back of your calf. The tight muscles and tendon suddenly yank on that attachment at the heel and on the sole of your foot in general. After you walk around a bit and get things loosened up, the discomfort eases. Then, after some hours of weight bearing, your inflamed, upset fascia starts to get more irritated and lets you know. Sitting for long periods may cause a similar effect to lying down overnight.

You can see that a big part of the solution is to open up the tight tissue so that it’s not pulling this way and can let the plantar fascia calm down and heal. If you have this problem, you will probably find distinctly tight, tender knots in your calf muscles and/or above your heel. Podiatrists typically prescribe stretching of the calf, which is good and necessary, but the trouble is that if you stretch aggressively without doing anything to loosen those tight knots first, you will probably just irritate and aggravate the situation more.

So here’s what you need to do: Feel around throughout your calves and ankles for tight areas, which may be exquisitely sore to the touch. When you find them, gently press and massage them. Experiment with the amount of pressure; you need to be firm enough to make a positive change, but you don’t need to torture yourself. Keep at it until the knots release and the spots aren’t so tender. I recommend doing this before you go to sleep and before you get out of bed in the morning, but anytime is OK. For some reason, massage of the calf is virtually never mentioned by podiatrists or in articles on plantar fasciitis, but I find it to be the most important aspect of treatment. You should start feeling improvement pretty quickly, maybe even immediately. You can also massage the soles of your feet themselves.

Heat may be helpful to help the muscles relax. Ice or cold packs may feel good on your feet to reduce inflammation. You may need to rest from your usual activities, especially if sports or excessive standing or walking are causing pain— but you don’t want to be so immobile that you end up with more stiffness and tension. Whatever makes you feel better is fine with me. I treat patients with acupuncture for the knotted muscles and inflammation, and I use microcurrent stimulation on the feet, since needling directly into the sole can be unpleasant. Professional massage, osteopathic manipulation or other manual therapy, or chiropractic could also be useful. Whatever you choose, self-treatment is going to be extremely important.

What caused the calf muscles and Achilles tendon to get so tight to begin with? There could be a number of factors, such as lack of exercise, too much muscle-building exercise without enough attention to flexibility, a previous injury that has led to muscle imbalances, or wearing inappropriate shoes.

Often adding arch support will go a long way toward solving the problem— although an overly intense or rigid arch support, or one that doesn’t fit well, can contribute to causing it, as once happened to me. Try different shoes and different arch supports to see what seems to work best for you. You don’t have to spend a fortune on orthotics to start with; begin with inexpensive store-bought types and see how you do. It’s possible that you will in fact need custom orthotics in the long run, but you don’t need to start there, and if someone tries to sell you on very pricey ones, I suggest that you put them off for now. Also, some people are comfortable with very firm arch support, while others need as much softness as possible to comfort their sensitive soles.

I have seen a couple of cases that didn’t respond to these basic strategies, but they are rare. It may take a number of weeks or even months for the pain to resolve completely, but you should be seeing definite improvement soon. If that doesn’t happen, something else is going on and you will want to look further.

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WordPress Gives a Helpful 2014 Blog Summary

The WordPress.com stats helper monkeys prepared a 2014 annual report for this blog.

Here’s an excerpt:

A San Francisco cable car holds 60 people. This blog was viewed about 3,600 times in 2014. If it were a cable car, it would take about 60 trips to carry that many people.

Click here to see the complete report.

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A Day at the Office, and the Day of the Dead

11/8/14

My workday started yesterday with a lady who is nearing the end of her life. She has a good deal of dementia, and although she is still recognizable as the person I’ve been treating for years, she is not quite that person anymore, literally a shadow of her former self. Who is she now? This lady’s daughter gave the opinion that when her father died, her mother died as well. Where did she go?

The day ended with my empathically witnessing the very troubled birth of a child whose mother was the person actually lying on my table. The child has been having terrible nightmares and visions. Our working theory was that these distressing images relate to a disaster that occurred two generations back, before the birth of the child’s grandmother, because they seem to depict such similar images. Is this trauma still stuck in the psyche of the family group? Is the little girl a version of someone who was physically present at the event? Why is this child the one carrying the trauma?

All that plus an extra measure of fatigue and stress to scrape away my outer layers made me especially conscious of the continuity and connectedness of human life. It’s a few days past Día de los Muertos, and this year I have felt the thinness of the veils as never before. (As I wrote that, I felt a touch from Fryderyk at my right side.) Most years I hadn’t noticed anything special at that time, though I appreciated it and cherished it as my favorite holiday.

But most years I didn’t know so many on the other side personally. Within the past year one of our cats passed, then the patient and friend that I’ve mentioned, then two of my husband’s relatives, then my cousin. Very recently there were two I only knew vaguely but my husband knew better, someone prominent in the music community and an artist who lived down the street from us. A week ago I made an ofrenda in the dining room, with silk flowers and an Archangel Michael votive from my patient’s house, and put up pictures of those I could.

Late that night I suddenly felt strongly drawn into that room. I paid attention and pulled up a chair next to the ofrenda. There was an incredible sense of peace, and as I gazed at the photos in turn, I felt the presence of each of the deceased, especially my patient, and very much including the cat. As you know, for me to reach out to the dead is nothing new, but they had never reached toward me in this way before. It was a wonderful benediction and blessing. I didn’t want it to end.

altar 2014

The theme of this year’s Marigold Parade, the Día de los Muertos observance in Albuquerque’s South Valley, was water (“No Se Vende, Se Defiende!”). Nature went along by dumping rain on us, the only rainy, chilly day in a period of gorgeous fall weather. The energy was a bit lower than usual, but my enthusiasm for the holiday was way up.  Here’s my attitude:

From a calendar owned by my patient, artist unknown

From a calendar inherited from my patient, artist unknown

I’ve encountered a reaction of “ewwww” from some folks who aren’t in tune with this celebration of the dead. I don’t understand why. The dead are no more or less than the same people we loved when they were alive, and our relation to them doesn’t change in any fundamental way. Our ancestors may be gone from this plane, but their lives inform and nourish ours at every moment. There is nothing foreign or frightening about them.

The depictions of the dead dressing up in their party clothes, playing music, eating, drinking and dancing charm me. Why not have fun, free from one’s earthly cares? Because I know that there is infinite potential to keep learning, developing, loving, and appreciating, and I want others to know it too, I like this kind of reminder. The images of the skull and the skeleton also remind us that under the skin we are all the same, and that all of us are equal in facing death, no matter what our station in life.

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An Invisible Patient

I thought I’d be writing Part II of my last health-care post at this point, but meanwhile something fascinating came up that I’d like to share with you.

More and more, I’m being called upon to do psychic work with my patients, although I never advertise or warrant that I can do that. They assume I can do it and trust me to come up with something useful, even when I don’t trust myself. Two weeks ago, on September 3, a patient asked me to help with something that seemed a bit outside my abilities. She, and the other person involved, have authorized me to tell about our experience.

The other person involved was my patient’s dear friend and business partner, who killed himself a couple of months ago after grappling with intractable mental and physical health problems and other frustrations. I’m going to call him G for Ghost, and his friend simply P for my Patient, even though in this case the patient was actually the ghost himself.

G has been in persistent contact with P since his death. Not in a frightening way, not any kind of possession, no attempt to control P, but he’s just always around. He’s talked with her often, with perfect clarity. He’s even commented on conversations she’s had with other people, which were not intended to include him, leaving her a bit peeved. When P asked if she could bring G to my office so that he and I could communicate, I didn’t understand what she wanted. Since she could hear him so well, and I likely couldn’t, why would it help for me to try to converse with him?

“He needs to talk with someone who isn’t me,” she told me firmly. The truth of this became obvious later when we had our meeting.

I’d already met G, briefly, at P’s last appointment. It’s not particularly unusual for spirit entities of various flavors to come in with patients, but finding myself nose to nose with a recently dead human being was still a little startling when it happened. I asked G if he had anything to tell us, and he hung his head and repeated, “Sorry sorry sorry sorry….” Poor guy, I thought. I tried to tell him that nobody was judging him and everything was OK now.

Later, P told me that G had been feeling terrible, both before and after his passing, about how much he had needed her to do for him, how much of her energy and resources he’d taken, and how he had hurt her by committing suicide. She said that the “sorry” message was very real and I had heard correctly.

It seems that G has been making every attempt to be helpful since, but his helpfulness may not be any more balanced or healthy than his guilt and shame. I wasn’t sure what to make of the message P relayed next, that G wanted to help me with my “balance of giving and receiving” because he felt that my patients were draining me. OK, I can somewhat see where he’d be getting that, but overall it’s not the issue he thought it was, and at any rate it wasn’t happening at the treatment he’d observed me giving to P.

I set up an appointment with P, and tried to prepare every way I could during the time leading up to it. I sent out repeated calls to Fryderyk, requesting his presence at the event; I had the feeling that things would be difficult, and I was hoping for backup. I got very little response.

P and I agreed that if nothing happened, we would just accept that and not worry about it. I set our chairs on either side of the treatment table, as if we were about to work on a physical patient who was lying there. On the table was the MacBook on which I’m writing now, with GarageBand open to record the session. We needn’t have worried that nothing would happen– as usual, G was right to hand.

G immediately reiterated his desire to be of assistance to me, and a moment later he was inside my body, trying to move my hands and look out through my eyes. This would have totally creeped me out if I hadn’t had such experiences with Fryderyk before; as it was, I stayed utterly calm. I didn’t think that G was any threat to me or that he had any ill intent, but still, this was exceedingly inappropriate. I told him in no uncertain terms that he was not allowed to use my body in this way.  It was useful that he made the attempt, though, because that showed me where he was coming from and what he was trying to do.

I told P what was going on, and added a bit about why I thought G was incorrect in thinking that he needed to save me from being drained by my patients.* P marveled that even after death, we can still project our own issues onto others. Well, as we discussed, we’re still ourselves when we die, and we don’t immediately become hugely enlightened, though I hope we can get a bit broader of a perspective even early on. G, it seems, had major issues with being able to ask for help and to feel OK about needing it. I can understand that, and it’s not foreign to me by any means, but as I told him, I get a great deal of help from both Earth-based people and the spirit world, and I’m very aware that I couldn’t manage without it.  Anyway, I thanked him for his offer, but made it clear that we would not be working together in that way, period.

It was becoming apparent to me that G believed he needed to work through a physical body, even though he had given up his own. I tried to convince him that he was far less limited in his present form, and could do whatever he might want or need to accomplish perfectly well. “I don’t even work in my own body half the time!” I exclaimed. But G looked to me (through my mind’s eye, not as a vision in the room) like a small, contracted, grey figure, not a powerfully glowing ball of energy, which is how I see a person in a healthy state. He didn’t look like he could accomplish much of anything, he was so closed up and shut down.

“Isn’t there anyone helping him?” I asked P. Normally, we all have our connections to current family, ancestors, guides and so forth, and we’re always told that when we die someone comes to take care of us and show us the ropes. I could not detect anyone or anything around G, and P couldn’t either. This seemed unimaginable, but my own vision, the messages P received, and her subjective experiences all said that G was completely alone except for his connection to his one friend. When I asked G about this directly, I heard the only verbal message I got from him that day, which was an impassioned, “I LOVE [P]!!!!”

Feeling perplexed, I set about trying to help G open up to the universe beyond the small area in which he’d confined himself. Right away, I sensed extreme resistance to this. Looking further, I discovered that G believed that if anyone out there saw him, any higher beings, they would immediately judge and reject him. I did my best to convince him that this was not the case at all, but he wouldn’t take that in. I talked about other messages I’d channeled and been told about, in which I’d heard how valuable and beautiful and precious an individual human personality is, and how loved we all are, as well as how much fun he could have in his new expanded state of being and how much good he could do. P and I kept up this encouraging conversation for a good while. At the same time, I kept doing energy work, as I would with a physical patient. I brought a column of illumination down into him (best I can describe that), and G began to expand and light up a bit. He still seemed extremely skeptical about what we were telling him, though.

At this point, I felt like I really needed some outside support. Unable to find anyone naturally connected with G, I sent out a plea toward Fryderyk, who I knew had done this sort of work before. I felt only a vague tendril of contact; it appeared to me that he and G reached their hands toward each other, but the connection felt tenuous, and I wasn’t sure anything was really happening.

Over an hour had gone by, and we were all beginning to feel that we’d said everything that could be said in that session. I knew that G still wasn’t the least bit ready to Go Toward the Light, but I had no more incentives to offer him. P reported that G was telling her, “She needs to go and have lunch.” I was feeling that way too. It was a day of 7 patients in a row with this in the middle, and I definitely needed a break.

When I checked my laptop, there was a message on the screen saying that GarageBand had crashed because there was too much data coming in too fast for it to handle. A simple recording of one track of ambient voices, with a lot of spaces between sentences– how could that be too much or too fast?

G left the room, and there was no question in my mind that he was gone. I didn’t feel that there was any residue left in my body or in the space. P felt him go, as well– giving her a little break! And the moment he was gone, Fryderyk was all over me, embracing me warmly, almost overwhelmingly. No words, but a feeling of “Good job! I knew you could do it!” He must have been observing the entire time. And really, I could do it. P and I were both completely capable of handling this sticky situation, and we both felt fine afterward.

But we didn’t succeed in helping G on to the next phase of his existence. When I saw P a week later, she reported that he was still around. All. The. Time. Her strategy at that point was to sit in her yard and meditate, expanding her own energy outward, trying to model this behavior and encourage G to do it along with her. It sounds like a reasonable response to the situation. This is all I know so far about the results of our session.

 

**************************************************************

 

As you know if you’ve been reading my posts for a while, I am all too familiar with the feeling of a malign entity invading one’s system. (See “A Case of Possession.”) G isn’t like that, and I don’t mean to lay any blame on him, at least not much– he’s doing more than enough of that himself, after all. He’s just confused, as far as I can tell. When my other patient died at her own hand last year, she had become much clearer and in a way well by the time she passed over**, but G died in a state of great distress, as far as I know, and didn’t have a chance to resolve anything. I don’t know how typical this is of suicides, but I wouldn’t be surprised if it happens a great deal.

I am also familiar with the feeling of having an invisible friend hanging around for days on end. Now that I don’t get a lot of concentrated time with Fryderyk, I’m nostalgic about it, but early in our relationship there was occasionally almost too much togetherness. Sometimes, after it went on for a while, I would begin to wish for time to myself, like can’t I even go to the bathroom on my own for gosh sakes? It was not unpleasant in any way to have him around, and I didn’t experience any interference with my daily activities, but I would just start to feel like I needed a little more room to breathe. I can certainly empathize with P’s desire to have her own space again.

There is another close parallel with my experiences with Fryderyk: the form that my interaction with P and G took was exactly like the “afternoon teas” Mendy Lou and I used to have with him. In both cases, the other embodied person in the room was getting verbal messages and for the most part I was not, but I was clearly picking up emotional and energetic impressions. Combining our two streams of communication, we were able to put together vivid and complete pictures of what was going on. The similarity says to me that the type of communication I received from Fryderyk when we were with Mendy Lou was more related to my personal mix of abilities than to his specific way of interacting with us. I’m still much more an empath than a telepath, and still a pretty small medium, I’m afraid.

As I worked on this today, I couldn’t help but radiate wishes to spend some quality time with my dear departed, and apparently those got through to him. When I settled down to rest for a while, my wish was granted. I’d been hoping to ask him about a subject that had come up in the past couple of days, the types of keyboard temperament (tuning) in use in his time. I wondered what sort of tuning he had preferred. It was a fairly technical question and I didn’t know if a reasonable answer was possible, but I asked anyway. The first answer was that if an instrument could be competently and completely tuned in some temperament, any temperament, and stay that way for a while, that would be great! Yes, for sure…. So then I asked him, “If you had an ideal instrument and an ideal tuner, what would you ideally prefer?”

As so often has happened, he gave me a reply that came in from a totally unexpected angle. Showing more than telling, he conveyed this to me: If he could have had anything he wanted in terms of tuning, what he would have wanted was to sing, to be able to shape the intonation and tone quality of each and every note without limitation. I felt a huge rush of air and sound through my body, vibrating everywhere, tremendous power and freedom. It was exhilarating, and it was something I want as well and have experienced all too rarely.

It was something his small, struggling body could never have done, but somehow he deeply understands what it can feel like. Perhaps I should see if he and I can try it together.

 
*This strikes me as amusing in light of what my former friend and colleague, whose patients I inherited, said about me– that because of the “evil spirit” Fryderyk hanging around me, I was draining the energy of my patients and everyone near me. Here another “evil spirit” was seeing things exactly the other way around.

**I had been pleasantly surprised, when I encountered her after her death, to find that she seemed peaceful, not stuck or confused. https://elenedom.wordpress.com/2014/01/07/get-right-while-you-can/

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All Healing Is Self-Healing, Part I

A few weeks ago I ranted about one aspect of our dysfunctional medical system, prohibitively high copays. Since then I went to see my chiropractor*, and he mentioned that his patients have been telling him that they would be coming in more often if not for their recently inflated copays. He added that in the past, by this time of year, patients would virtually all have met their deductibles, but now deductibles are so high that 80% of them have not.

What amazes me most is that we are all putting up with this. But then, we’ve learned that we have no power within this system. Many of us have also learned that we don’t have much power over our own health. More than anything, that is what is going to have to change if we are to have any hope of getting health care on a viable and sustainable course.

Last time I gave you a link to a post by my friend James Rolwing, which he began with this crucial statement: “All healing is self-healing.” Please think about that for a moment. Does it sound true to you? Does it have exceptions? Does it feel liberating, or does it make you a little uneasy?

All any of us in health care can do, for any amount of money, is to aid the body’s and the mind’s own natural healing processes. Even in the case of the most drastic interventions, such as a joint replacement or organ transplant, the body must take what has been added and make it work, while repairing the tissue around the new portions. Surgery can remove damaged tissue or stitch it together, sometimes in truly ingenious and astonishing ways, but there is no force on this earth that can heal surgical incisions except the body’s own innate ability. We do what we can, and then we must wait.

But what about drugs, you say. Drugs make direct changes in body functions. Yes, but the body must metabolize and make use of the drugs, and individual bodies do that in individual ways.

When I do acupuncture I am acutely aware of the fact that all I can do with needles is to give signals to the body about what it needs to do to get back into balance. I can use needles to talk to the body through obviously physical means, engendering tiny electrical currents and stimulating the release of substances such as neurotransmitters and hormones, as well as the subtler energetic signaling that medicine understands less clearly. I can ask for increased circulation or for excess fluids to dissipate. I can ask for whatever I care to, but then the body will do exactly what it wants to do and is able to do, no more and no less.

This is not so much a limitation as a gift, though it can be frustrating to find the optimal way to get the body to respond. Most of the effort and cost in American health care goes to dealing with chronic and often very confusing conditions, and there is contention and controversy about how to treat them. If we say that we want people to have access to health care, what exactly do we want them to be able to access? What is our underlying belief system about how to deal with diabetes or fibromyalgia or cardiovascular disease or even simple aging? I think you have a pretty good idea of how things stand in the medical world at present. We do a lot of fixing but not a tremendous amount of healing, lots of sick care but not so much health care.

How do we find a path to health for ourselves as individuals and as a society? How do we take responsibility for our health in concrete ways? We know about fundamentals like nutrition and exercise (though even those are fraught with controversy), which in themselves could transform our lives if we would do what we know we should. There is far more that we can do, at least if we are fortunate enough to have access to the information we need and the openness to make use of it.

Here James outlines two possible ways of thinking about our bodily discomforts:

“Essentially, we have two choices of dealing with a symptom. We can drive it back below the threshold of our awareness (a suppressive approach) or we can participate with it (an expressive approach). With suppression a door is closed, and with expression a whole world opens up.

“Most of what is typically described as healing occurs as the result of suppressive mechanisms. Painkillers and antidepressants are obvious examples, but any type of therapy can employ a suppressive approach. It is often a fear-based strategy, as we unconsciously fear to examine what is underneath the symptom.

“Expressive healing describes the mechanism of self-healing, and views a symptom as an indication that something within us is asking for acknowledgement, most often trapped or repressed feelings and emotions. Relief or resolution occurs as the result of recognizing and giving expression to these underlying sources, because the symptom was only there to point us toward the deeper cause in the first place.”

http://rolwingjames.wordpress.com/2014/04/13/the-intervention-fallacy-part-i-how-it-starts/

While I was working on this post, my right arm and hand were giving me a lot of grief, impossible to ignore, just in time to help me think about how to apply what I was writing about. That was what sent me to the chiropractor. You might wonder why I needed to/chose to do that, since one’s physical structure ought to be able to right itself naturally. In fact, that’s an essential concept in chiropractic, the body’s innate wisdom and healing capacity. Well, I had been doing everything I could come up with on my own, and it wasn’t enough. I was still having disabling pain and dysfunction, and I needed this kind of assistance. (It’s OK to acknowledge that we can’t do everything alone; that’s not abdicating responsibility for oneself.) Getting my bones pushed back into place helped the acute situation quite a bit, though that also brought other aspects of the pattern to light, which I then needed to deal with. I still had to work with the emotional issues that had been stored in that area of my body; that is, I had to do expressive healing. It was very clear that I had to do that, and that the pain would not resolve otherwise. In the midst of it I went for an Alexander Technique session** to get some guidance in releasing the habitual tensions that were feeding into the problem and to help move the stuck emotional content. It all took a lot of time and effort, especially considering that most of it was a matter of simply letting go! I’m doing a great deal better now. Maybe I even know a bit more about how to avoid this in the future.
Here’s a case for you to contemplate:

A patient of mine who is disabled and on Medicare hit the “donut hole” recently.  A drug which has helped immensely with his diabetes will now cost him $295 per month. That will be the case for four months, one third of this year, even though he is insured— all the way till next year. (This would not happen in the same way with private insurance or with Medicaid, only with Medicare.) His family makes $1000 per year too much to get any kind of extra subsidy. He’ll never get out of the donut hole, because he won’t be able to pay out of pocket up to the amount where coverage would kick in again. They might as well ask him for $2950 per month— he simply can’t afford that $295. He’s already tried the other available medications, some of which are cheaper, and this one worked tremendously better. I could see a marked difference in his condition with it, and I’m sure his PCP was delighted to see what it was doing. So much for that.

If complications from his diabetes put him in the hospital for even one day, that will cost us all more than we would pay to cover his medication for the rest of the year. Our country is being financially stupid as well as cruel to this man. And our vaunted medical breakthroughs are meaningless if our doctors can’t get them to the patients.

This gentleman is a superb energy healer himself, and he does everything as naturally as he can to take care of himself. He has had some success in the past with herbs to control his troublesome symptoms, and he is exploring herbal options again. After a period of being enraged with the system, he decided that the present situation might be an opportunity to find a better way to deal with his blood sugar. At least, he pointed out, he won’t have to worry about the potential side effects of the drug. He already does all the obvious things with diet and exercise, you understand, and with his mental attitude. We’ll see what else he and I can come up with.

Update!!!  My patient has been able to get his meds through a free sample program at Presbyterian.  It took quite a while before this happened, and when he first (and second and third) inquired he wasn’t told this was possible, but the system did come through for him.  He was already developing preventable problems while waiting, however.

 

*Terence Timm, DC. I’d refer you to him except that (waaahhh!) he is retiring very soon.
** with Karen DeWig. http://alexanderabq.wordpress.com/

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Killer Copays

Most of us seem to enjoy complaining about our so-called health care so-called system, but not a lot of clear paths for improvement have been put forth. I have come to think that above all, we have a failure of imagination. We cannot envision another way of doing things, or at least a way out of the present situation, and so we continue to put up with a reality that is increasingly insupportable. We tinker around the edges, but nothing more. As Dr. Dean Ornish put it, “We spend so much time in medicine mopping up the floor around the sink that’s overflowing without ever turning off the faucet.”

Much of what I’m writing today will focus on a small aspect of the system, copays, and will not offer grand visions for the future, but I would like to drop this idea into your head so you can let it grow in the background: We created the present situation. We can create something else. What we have now is not ordained by God or nature. It hasn’t even existed for a very long time, only a few decades.

After you’ve read this post, please look up the 2012 film Escape Fire, which outlines just how completely screwed we are and what we can do about it. You can find it here:  http://www.escapefiremovie.com/  It’s also available through Netflix.

Escape Fire is based on a book by Donald Berwick, MD, the former head of Medicare and Medicaid. He wrote it early in the 2000s, and you’d think that a decade later we would have figured a few of these matters out, but as far as I know we haven’t made a single one of the changes he recommended. The idea of an “escape fire” is that if one is about to be overtaken by a forest fire, one can burn an area on purpose to provide a path to escape. The film recounts the story of a group of firefighters who were in this type of situation. Their leader dropped a match on the ground and burned a circle around their position, using up the fuels that would have fed the fire. He told the others to stay in the circle with him, but they took off, insisting that they could get out safely. Guess who survived. Dr. Berwick’s point is that we have obvious paths to escape right in front of us, but we refuse to take them, or even to see them.

Dr. Berwick pointed out that people within the health care industry do exactly what makes sense to them where they find themselves. It’s just that the system contains such incredibly perverse incentives that they often do things that have ill effects for the country as a whole.

Recently one of my elderly patients canceled her appointment for the next day. The reason was that she had to see her eye doctor, and the copay for that is $45, meaning that she wouldn’t have the money to pay even the extremely reduced price I would have charged her as a low-income senior who doesn’t have insurance that covers my services. This lady lives in a subsidized retirement apartment complex. Some of the people who live there have income of less than $1000 per month, and few have much more than that. A copay of $45 is huge for them, possibly even requiring saving up over a couple of months. These folks have Medicare and often other coverage, but strangely, it’s still quite possible to face daunting copay amounts.

A few weeks ago, an insurance company representative told me that high copays do not prevent access to care. Clearly, they do. Copays and deductibles* are both going through the roof. I wrote to her company, one of the major insurers in our area, one which pays only 2/3 of usual and customary fees for acupuncture, as follows:

“Copays keep increasing in general. I understand that at least in part this is caused by attempts to limit increases in premiums. What is troubling is that in many cases copays are equal to or greater than the amount insurers actually reimburse for a given service. As copays continue to go up, this situation is likely to keep getting worse.

“Within the ____ system, the most extreme case I’ve seen involves City of Albuquerque employees. They have a $55 copay for acupuncture, but ___ only pays $43.73 for acupuncture. [Your representative] said that she thought in this case the member would only be expected to pay the $43.73, but that is not how it works. EOBs show clearly that the full $55 copay is expected. And providers are not allowed to discount copays and can get into trouble for doing so.

“It is more typical these days to see a $40 copay for ____ members, and has been for a couple of years now. That means that much of the time ____ is paying a princely $3.73 for acupuncture, and the patient is paying nearly the entire charge. When you include the fact that ____ limits members to 20 treatments per year, the total paid for the year can be as little as $74.60, less than the price of a single appointment for most medical services.

“In both of these types of cases, the member and the employer (often through the taxes we all pay) are paying for coverage for acupuncture, but they don’t get anything that can really be called coverage, and in the case of the highest copays, they have a kind of negative coverage. It’s an advantage to me as a provider to have the patient pay a larger copay, but it’s still painful to see them treated so unfairly.

“I imagine that when the HR department or whoever set up these copays were in discussions about how their plans would work, the amounts sounded quite reasonable to them. Perhaps someone said, ‘I don’t know, what does acupuncture usually cost?’ and someone replied, ‘Well, my acupuncturist charges $70.’ It might not have occurred to them that $55 would be higher than the reimbursement amount.

“(After all, usual and customary insurance payments for acupuncture alone are in the range of $62-65, not counting any amounts for E & M codes or other services. ____ is unusual in paying only about 2/3 of that— an amount that has not changed for a number of years even as patients pay more and more. This exacerbates the issues with copays.)

“I don’t know about how other types of providers are affected. I do know that chiropractors have some similar issues.

“Copays are charged for us DOMs at the ‘specialist’ rate, but since we are not reimbursed at anything like the amounts cardiologists, etc. get, the copays are a much larger percentage of the price. I understand that PCP visit copays are kept lower because insurers want members to see their PCPs to try to catch problems early, but often the PCP can’t do anything and simply makes a referral anyway, meaning that the PCP visit is a waste. Visits to DOMs, DCs and PTs are relatively discouraged by the higher copays, even though we are saving insurers money by helping patients avoid more expensive interventions such as surgeries— not to mention helping the patients relieve their suffering and improve their overall health, which ultimately reduces costs as well as being worth doing in itself.

“[Your representative] said that members have far wider benefits than just acupuncture, which obviously is true, and a member who has a major health problem may end up with much more value paid in benefits than they pay in premiums in a given year. However, this does not change the fact that members with high copays for acupuncture are being sold a benefit that they don’t truly receive. It’s rather like going into a store to buy a shirt, and being told that although the shirt normally costs $45 and most people pay that or less, you have to pay $55 for it.”

So costs to consumers and the country at large keep going up and up and up. In what aspects of the system are those costs increasing so persistently? Let me tell you, payments to doctors are not the problem. We’ve been seeing flat or even decreasing rates of reimbursement. Medicare and Medicaid in particular squeeze providers, and as shown in a heartrending segment of Escape Fire, often the only way a clinic can stay in business is to pack in more and more patients. Again, providers are doing what appears to make sense from their perspective in their corner of the system. But not only is this compression of appointments terrible for patients, especially those with more complex needs, it can actually raise costs. Primary care doctors who don’t have enough time to figure out what’s going on with a patient are likely to refer that patient to a specialist, costing dramatically more, whereas with more time to think, the PCP might well have solved the problem and come up with a treatment plan without making a referral.* So reducing payments for primary care to absurdly low levels is classically penny-wise and pound-foolish. “There is no more wasteful entity in medicine than a rushed doctor.”
http://www.nytimes.com/2014/07/21/opinion/busy-doctors-wasteful-spending.html?contentCollection=opinion&action=click&module=NextInCollection&region=Footer&pgtype=article&_r=3

I would like to propose a simple rule that copays may not be more than 50% of the amount reimbursed for a given service. Period. I truly believe that there is more than enough wasted money, far more than enough, to make this happen. I would also like to propose that resources be redirected into primary care and especially accessible clinics for the most vulnerable portions of the population, like the ones being seen by the frustrated PCP in Escape Fire. Continuing to cut already-thin payments to practices like that makes no sense.

These of course would only be stopgap measures. Next time, I’ll take up some thoughts about self-care and our responsibilities toward our own health. Meanwhile, I offer you one more pithy post to chew on: 
http://rolwingjames.wordpress.com/2014/04/13/the-intervention-fallacy-part-i-how-it-starts/

*https://elenedom.wordpress.com/2014/02/04/health-care-access-and-why-pcps/

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I Could Have Gotten Out at Any Time

 

Getting near water was almost worth all of it.

Getting near water was almost worth all of it.

I’ve debated about whether to post this description of a rather embarrassing event that I shouldn’t have allowed to happen.  A while back, I was told, “Everything you need to know is in this story.”  Maybe you’ll learn something from it too.  I’m reminded of the lessons every day by the scars on my leg where it was torn by the wire of that chain-link fence.

 

On May 3, feeling exhausted but in need of exercise, I decided to try to do something good for myself and take a nice walk down by the river at the Rio Grande Nature Center park. It was an unusually warm day, and between trying to finish laundry and chores and wanting to miss the hottest hours, I went late. I knew that they closed the parking lot at 5 pm, but I never park there, not being interested in paying unnecessarily nor in having my car locked in, so I wasn’t worried about it. In previous years, it had always been possible to get in and out of the park on foot at any hour.

I went in through the front gate at about 4:50. An APD cop was cruising through the parking lot. He didn’t tell me that I ought to get out of there, which reinforced my sense that it was fine to be there– another great moment for our dysfunctional APD. Perhaps, since I was striding purposefully, he thought I belonged there. Another woman was also walking in the park, but in the opposite direction. I assume she got out before 5.

Well, you guessed it– the entire park is now enclosed with chain-link fence. It’s no longer possible to get in or out after 5. They don’t make any announcement when they close. They don’t walk through and check. They just lock the gates and leave. I was trapped.

I felt sure that there must be a way out. I walked all around the perimeter of the park itself, including the education building and the animal rescue center. It seemed like surely there must be a human being left in the place, but there was no one. There is a large expanse of open space next to the park, and I thought there ought to be a place to slip through somewhere. There wasn’t. They have tamed the whole thing.

I found a gate near the road that looked a little bit lower and more accessible. To get to that, I had to clamber over a low wire fence in some tall weeds. I started trying to haul myself up over the gate. It proved to be impossible. I just wasn’t strong enough. Analyzing the geometry of the situation in retrospect, I can see that even with considerable upper body strength, it would have been unlikely that I could have made it over. I was trying to fold the top of the wire mesh over a bit, but that wouldn’t have been enough. I couldn’t get my toes into the openings between the wires, and even if I could have gotten over the top, I would have been injured because of the wire ends sticking up.

Which caught in one of the openings in my shoe as I tried to get my left leg over. (What I would have done had my leg gotten all the way there, I’m not quite sure.) So then I was ridiculously hanging there with my right foot on a support in the middle of the gate and my left stuck on the top. I think that was when I got the most hurt. Eventually I was able to get my foot unstuck and land on the ground without a total disaster.

An older couple was biking along the road in my direction. I flagged them down and asked if they had any idea of a way out. They said I was probably doing the best possible thing already. The woman tried to encourage me when I said I wasn’t strong enough to get over; she said, “Of course you’re strong enough, if you get enough adrenaline going.” No, I wasn’t. I felt hopelessly weak, and more drained than ever. And stupid, of course very stupid. And in pain from the cuts and bruises I had managed to sustain. I never did figure out exactly how I’d gotten cuts all over my arms and legs.

I had my phone in my pocket, but I didn’t want to try to call the cops for a rescue because I figured they’d cite me with something. There was only one other thing I could think of– maybe the opening under the front gate was tall enough for me to get under. As soon as I took a good look at it, I could see that it was. I slipped underneath and out, reasonably gracefully and with no more damage except for the dirt, which added to my feeling of ignominy.

I could have gotten out at any time.

 

 

 

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