Wednesday, December 26, 2012

I fell through a big hole...

Baruch Hashem, I am blessed with much intelligence, and a reasonableness that enables me to weather the vicissitudes of Israeli life, both socially and professionally, and most importantly in my dealings with any or all of the bureaucratic “systems” in place here.  I place the word “systems” in quotes, because quite honestly, I do not see any real system.  The words “streamlined processes” are not heard here, and have no meaning here.  

I was prepared to accept all this.  But my most recent experience tells me that there is much change needed.  I think a Patient’s Rights should also be about being treated with dignity and respect and about there being open lines of communication between the various “parts” of the “system” which the  Patient is required to navigate when in need of medical care.  Perhaps my having grown up in the US where processes are streamlined, where everything seems happen smoothly and seamlessly has spoiled me.  The health care system in the US, while unaffordable and unattainable for many (Obamacare notwithstanding), is at least streamlined and patients are treated carefully, and lines of communication appear to be more open and used. 

Here is my story:  (it is long, but please read to the end.  The issues I raise have to do with both the bureaucracy of the financial aspects (Sharap/Kupah) and with the lines of communications between doctors.)

I made aliyah in August 2011.  About six months ago I began a search for an orthopedic surgeon who could correctly diagnose and treat a leg deformity of mine that was causing me pain.   The first two doctors I saw, with hafnayot from my family doctor, were unable to do this.  I then, on my own, searched out a top notch doctor – by looking through the Hadassah profiles of medical personnel.  I found Professor Meir Liebergall, who is the head of Orthopedic Surgery in Hadassah.  I contacted him and described my problem. He then put me in touch with Dr. Vladimir Goldman. Dr. Goldman is the head of Limb Lengthening and Deformities.  Within two weeks I had an appointment with Dr. Goldman.  He was very thorough in his examination of me, even accompanying me to the X-ray department to provide oversight for the x-rays he requested – he wanted to be sure they x-rayed exactly to his specifications.   His diagnosis was spot on and he then requested a CT scan.  For that I needed a hitchayvut.  A request was sent to Maccabi via my family doctor for the hitchayvut.  It was initially denied, requiring my family doctor to supply more information, and then it was approved.  I took the hafnaya and hitchayvut and went for the CT scan.  Even though I had gone to the wrong Hadassah center, the personnel there were nice and arranged for me to have the CT scan there – right then and there!  I was , as you can imagine, quite impressed with this. 

I then made an appt. with Dr. Goldman for a follow up to review the CT Scan.  It was at that time that I met Professor Meir Liebergall who was providing oversight for Dr. Goldman.  Together, the three of us looked at the CT scans and Dr. Goldman explained everything to me and then described the surgery to correct the deformity.  I remember being a bit shocked initially as I learned the  scope of the surgery – it would involve making two cuts to the bone – one long vertical cut and one short horizontal one.  The bone(s) would be moved into the correct place, and pins inserted to hold them together which would then be screwed to an external device – a Taylor Spatial Frame.  I would wear this frame on my right lower leg for three months.  I agreed to have the surgery.

About a month later I was given a date for the surgery:  December 25, 2012.  That was four months out at that point.   I immediately was in touch with the Sharap office of Hadassah Medical Center, as I knew that since I had chosen a private doctor, I would need to make my arrangements for payment through Sharap.  It was my understanding that if I chose a private doctor, my kupah (Maccabi Magen Zahav) would cover a portion of it (less than if I chose a non-private doctor) and I would have to pay the balance out of pocket.  Sharap informed me that everything would happen a few days before the surgery.  I then explained to them that I needed to know sooner the amount my share would be as I would need to make arrangements to get that money in hand to pay it.  They understood and told me they would be in contact with my kupah to ascertain what that amount would be and they would be in touch with me.  BTW, I wear hearing aids and using the phone is VERY difficult for me, in English which is my native language, and impossible in Hebrew which is not.  Throughout all this I succeeded in requesting and receiving all communications via email.  In this, the service was good.  Shortly thereafter, Sharap informed me that they had been in touch with Maccabi, and that my share of the payment would be 5,491 NIS.   At this point Maccabi was now aware, that I , Rachel Stern, a participant in their Magen Zahav supplemental coverage, was scheduled to have surgery on December 25, 2012, with Dr. Vladimir Goldman, as the primary surgeon.   There were no secrets here. 

I made the arrangements necessary to ensure I would have the money available to pay for my share of the surgery.  I put all the wheels in motion arranging things in both my personal and professional life to accommodate up to three weeks of being “out of commission”.   And then I waited.

About three months before the surgery, I took ill.  It started as a cold, turned into a sinus infection, and then wound up as bronchitis.  This has been a normal pattern for me with regard to upper respiratory infections/illness.  For about 25 years of my life I was exposed to second hand smoke by my mother who was and still is a heavy smoker.  I have always felt that it is this that made me susceptible to upper respiratory infection.  I usually wind up with bronchitis, and a cough that lingers.  Only this time, it lingered far longer.  I saw that the cough would likely be with me at the time of the surgery.  I was very concerned. I felt that it could be dangerous for me, with regard to general anesthesia. 

EVERY DOCTOR I saw on my way to the date of the surgery was informed by me that I would be having this surgery.  I asked every doctor about this issue.  Every doctor informed me that it would not be a problem.   I emailed my surgeon and told him about my cough.  He, too, assured me this would not be a problem.  My family doctor, the pulmonologist, the ENT, my surgeon, all knew about my coughing.  I had done bloodwork, x-rays, eeg, ekg, spirometry, and other bedikot – all either as routine in preparation for the surgery, or in effort to cure the cough (or both).   On Monday, December 17th I went to Hadassah to the pre-op clinic for a pre-op workup.  There I met a nurse, an anesthesiologist, and an orthopedic doctor.  I told EACH one about the cough and asked if it would pose a problem.   Each one assured me that it should not.  I saw them writing things down in my charts and forms (albeit in Hebrew) and I assumed they were making notes about the cough as well.  I still am not sure if they did so or not. 

The day before I went to the pre-op clinic I was informed by Sharap that Maccabi would NOT cover my surgery. They were claiming that on the day of my surgery I would be six days shy of one year of participation in Magen Zahav.   I immediately understood what had happened.  When I arrived in Israel, at the airport I chose Maccabi as my kupah.  About a week later, I attended a NBN klita fair in Jerusalem.  Maccabi had a booth at the fair and I went over to it and sat down with a Maccabi representative.  She and I discussed the options for supplemental health insurance and I ultimately choose to sign on for Magen Zahav.  I filled out the forms and went home, feeling secure in the knowledge that I was “covered”.   A couple of months later I was sick and needed some medication. I had gone to the Maccabi pharmacy to purchase the needed medication (prescription).  When the price was stated to me I was taken aback at the cost and said as much to the pharmacist.  His reply to me was, “Well, if you participated in Magen Zahav, it would be less expensive”.  I explained to him that I was indeed a participant and he double checked and said, “No you are not, according to the computer”.  I then went to the Maccabi office to check this out.  I was told that I had never been signed up.  The woman who helped me signed me up right then and there. I erroneously thought I was signed up “retroactively”.  Hence, by my reckoning I was in my second year of participation for the surgery, but by Maccabi’s I was six days shy.  Sharap told me I would have to go into the Maccabi office and request a “kitzur” of my account.  This I did and was told I would need to write a letter to Magen Surgery to ask for this.  This I did (in Hebrew with the help of two friends).   On December 18th I sent the letter to Magen Surgery.  This was just 7 days before my surgery!  Two days later, I received the response from Magen Surgery that they would forgive me the six days and would cover the surgery.  

That same day, I received a call from Sharap, again telling me that Maccabi would not cover the surgery.   This time the reason give was that Dr. Goldman was a “private doctor” and they would not cover him. I would have to choose a different doctor.  I argued, unsuccessfully, that they had known this since FOUR MONTHS AGO, I was given an amount based on them covering him, and that at the last minute they should not be changing their tune.  Finally, I turned to Dr. Goldman and explained what was going on.  Dr. Goldman then told me to give Maccabi the name of the doctor who would be assisting him in the surgery, Dr. Naum Simanovsky. This I did, and Maccabi agreed to cover him.   By the time I got this resolved it was Thursday afternoon, just four days before the surgery.  Now suddenly, the amount of my share rose by 2000 NIS.  As you can imagine I was none too pleased to discover this.  However, I decided to suck it up and just pay it.  I had been told I could pay it the day of my surgery.  (I had also explained to them that I was paying in CASH (mezumanim).  (Let’s leave out of this story WHY I was doing that).

On Monday, the day before the surgery, at 4 PM I get a call from Sharap that I have to come in right away and pay.  Well, even though I have a car, I could NOT just drop everything (my grandchildren whom I was babysitting) to go to Sharap.  So Sharap tells me that if I am paying that day, then my surgery is being moved from first thing in the morning, to the third slot.  Of course I was not happy about this. I wanted to have my surgery early, when my surgeon would be alert, fresh and awake.  Again, I turned directly to my surgeon (he is a real mensch, by the way) and informed him of what was happening.  He assured me my surgery would take place on time.  I should show up at 6:30 am as planned.  This I did, and my sister came and met me there. First I was sent down to the Miyun Kabbalat Cholim where I paid for my surgery – 5,491 NIS in cash!  Then I returned to the fifth floor.  Everything happened very quickly. I was given gowns to change into, placed on a gurney and wheeled to the OR.  I was in the prep room in front of the OR and already hooked up to an IV.   We were waiting for the anesthesiologist.

Now before I tell you what happened next I want to refer to my state of mind.  I was very nervous, very anxious, and scared.  I was about to go under anesthesia which can be dangerous under the best of conditions, and my leg was about to be cut open, cut in the bone, and metal screws inserted into me.  I would wake up in pain, and on PCA Morphine (Patient controlled analgesia, morphine).  In the days that led up to this point I was stressed to the max in my dealings with Sharap and Maccabi – dealings which to my mind could have been taken care of MONTHS in advance.   All the information that Maccabi need to process my coverage, they had from the very beginning.  None of it was hidden or secret.  But they chose to deal with my account only days before the surgery, needlessly stressing me out when I was already stressing with worry over the actual upcoming surgery.   Now, I was sitting on a gurney, a black mark on my leg (courtesy of my surgeon), a white bracelet on my right wrist, and a catheter and IV hooked into my left hand. 

The anesthesiologist arrived.  He was none other than Dr. Alex Avidan, Senior Anesthesiologist.  I coughed.  And then I coughed some more.   He questioned me about the cough.  He was frowning. This was not good.  I told him everything about the cough that I had told all the other doctors I had seen on my way to that point!   He then went and had a  conversation with Dr. Goldman.  He came back to talk to me.  He told me “he is very worried about that cough”. He told me that he did want to put me under General Anesthesia.  It was too dangerous with that cough.  I asked about regional anesthesia.  He said it was an option but not a good one. Why?  Because if, G-d forbid, anything were to happen, he might have to administer General Anesthesia, and again, that would not be good.  So, long story short, the surgery was not performed. 

But I did ask, ALL the doctors that were there – WHY was this not addressed sooner?  My coughing was not a secret. I told everyone about it. I asked if it were a problem.  Why did it have to wait until I was sitting on the gurney, butt naked except for a flimsy hospital gown, already hooked up to an IV, just minutes away from having the surgery to learn that it was NOT okay?? From beginning to end the lack of communication along all lines from Sharap to Maccabi, from doctor to doctor, FAILED.

This is no way for a patient to be treated.  Patients are already stressed out, worrying about their health and trying to take care of themselves.  I had wanted to spend most of the week before my surgery relaxing and calming myself down so I could go into surgery, and under anesthesia in a good state of mind.  I know how crucial this is to healing.  It is one of the great intangibles of health care, that costs nothing, is for patients to be able to “self heal” using various methods of positive imagery, calming and de-stressing, and of course, laughter. 

Throughout this entire ordeal I tried to remain calm.  I tried not to stress too much.   But by the time I was on that gurney, I was stressed to the max.  And then,  MY concerns were confirmed and the surgery did not take place.  I now have to figure out how to get rid of this cough – which to date has stymied everyone – my family doctor, my ENT, and the pulmonologist.  I will be seeing an allergist soon.  Dr. Avidan says I must be 8 weeks cough free to have the surgery.  I will have to go through this process  ALL OVER again, needlessly!  I will once again have to make accommodations in both my personal and professional life to accommodate a new surgery date.  I have plans to move this summer, and now I have no idea if and how all this will happen. (I HAVE to move, I will no longer be able to afford to remain where I have been living for the past year and a half.)

I do not know if sharing my story will have any impact whatsoever. I do not even know with whom I could or should share it that it would make an impact.  But what I just went through is something that NO PATIENT should have to go through.

I think my doctors are terrific doctors.  I have asked for and received the promise that Dr. Alex Avidan will be my anesthesiologist when my surgery is re-scheduled.  He is a doctor who CARES.  I was blessed to have him come to me. Dr. Goldman is a mensch of the highest sort, an amazing person.  Everyone I dealt with – doctors, nurses, people in Sharap, people at my kupah, were all wonderful.  But that does not make up for the huge gap, the huge canyon, through which I fell.  

Friday, December 21, 2012

Jumping through the hoops of the health care system in Israel...

I go in for my surgery on Tuesday and I am nervous as hell.  The process of getting my surgery to be paid for by my insurance, here in Israel, has been rather daunting.  Just so you all understand:  I am from the US and I moved to Israel just over a year ago.   In the US even though health insurance is ridiculously expensive, and does not cover enough of costs, it is a remarkably streamlined process which can be effectuated months in advance and can take a few days to get set.  Here the process is NOT streamlined in the least and everything takes place at the "last minute".  That can be quite hairy for someone who may not have enough moolah to cover anything that may not be covered.   So here is how it panned out for me.

It was about six months ago that I initiated the process of diagnosis and getting recommendations for correcting the issue.  As soon as I learned it would take surgical intervention, I agreed to the surgery and began to put the wheels into motion to enable it.  First, I had to wait to receive a date for the surgery.  That took about a month of waiting and it was scheduled for December 25th - four months out from the time I received the date.  I immediately asked what the procedure was for getting it covered by my kupah (health insurance).  I was told that since my surgeon is a "private practitioner" I would need to contact the "Sharap" office at Hadassah Hospital, where my surgery would take place, and the Sharap office would be in touch with my kupah and then they would contact me.  But, I was told I would not know anything until a few days before the surgery!!!  At that point I explained that I needed to know at the very least how much my share of the cost would be, due to the fact that my funds are tied up in the States and it would take me some time to arrange for the release of the funds to pay for it.  So Sharap understood and contacted my kupah and got me the info.  In effect, they "neogiated" with my kupah about this.  Ok, fine. 

Last week, I was contacted by Sharap and told that my kupah was refusing to cover the surgery because I was not a participant in their Gold plan for a full year -- I would be shy by SIX DAYS on the day of the surgery!  That is by THEIR reckoning, not by MY reckoning – what happened is this:  when I arrived in Israel, just off the plane, I was met by an agent from the Jewish Agency and told to choose a health insurance provider.  I had done some research before I arrived and I chose Maccabi.  Then, a week later I attended the NBN Klita Fair in Jerusalem.  I knew there would be a booth there for Maccabi and I would be able to select a supplemental health coverage plan.  I went to the Maccabi booth, sat with a Maccabi representative and chose Maccabi Magen Zahav. I filled out the forms, and then went about my way, feeling secure in the knowledge that I was covered. I had been assured that all my info would be “put into the system” the very next day. 

A couple of months later, I was ill and needed prescription medicine.  I went to the Maccabi Pharmacy to fill the prescription.  The price seemed rather steep and I said as much to the pharmacist.  His reply to me was “If you were a Magen Zahav participant it would not be so expensive”.  I told him that I am indeed a participant in Magen Zahav. He double checked and no I was not. So I went down to the Maccabi office to find out what was going on.   There, I spoke to a lovely woman named Nochi (just so you know, I have found EVERYONE in the Maccabi office in Modi’in to be exceedingly nice and helpful).  She confirmed that I was NOT a participant and there was no indication that I had ever signed up.  But she signed me up right then and there.  I erroneously thought my participation would be counted as retroactive from when I signed up. 

So, back to Sharap informing me that Maccabi would not cover it due to my being six days shy of a full year of participation in Magen Zahav.  The Sharap office suggested that I needed to go into the Maccabi office and ask them for a “kitzur” of my account (shortening of it) to allow me to have the surgery and for them to cover it.  This I did, that very evening. (Yes, they have evening hours!)  There, I was told I needed to write a letter explaining all this and requesting the kitzur. 

With the help of friends I wrote a letter which I then sent to Maccabi Surgery.  It was an excellent letter, even my surgeon said so when I shared it with him.   It did the trick and Maccabi agreed to cover the surgery.  Great! Or so I thought.  That same day, I was contacted by Maccabi and told that they will NOT cover the surgery because the doctor I chose is a “private practitioner”.  I was kind of surprised (although not so much because now, I was used to expecting the other shoe to drop!).  I told them that I had addressed that issue by dealing the Sharap office which had already been in touch with Maccabi and had already negotiated the fees.  It was to no avail.  So, I explained this to my surgeon, not knowing what else to do.  Maccabi wanted me to choose another doctor – and I would NOT do that.  My surgeon is the top doctor in the field and I trust him implicitly.  I would not choose any other doctor. 

Well, he came to my rescue.  He told me that another doctor who will be assisting him would be the name we would give to Maccabi.  Maccabi would cover him.  So, I did give that name to Maccabi and sure enough they agreed to cover him.  I suspect this is a game that is routinely played by the doctors and insurance companies here.  

But now, Maccabi requires a new hafnaya (referral) naming the new doctor.  Again, I turned to my surgeon who told me “No problem, we will get a hafnaya to them on Sunday.”  Mind you, my surgery is now four days away and on Sunday will be two days.  When I was told initially that everything gets arranged at the last minute, I realize now that was the honest truth!!

Personally, I think it is a very bad way of doing things.  An individual who is facing major surgery, scary and painful surgery is already stressed out about that and working hard to be calm, relaxed, and positive – which is crucial when one is about to undergo anesthesia and surgery – does not need the added stress of worrying about whether or not the surgery will be covered by their kupah at the very last minute!  It is something that should be worked out WELL in advance of any surgery that is PLANNED.

In any case, it appears that everything is working out as it should and as always I give my thanks to Hashem for His hand in it.  I know he is orchestrating much of this for me! 

Tuesday, December 4, 2012

Fitting In

Last night I went to a Bar Mitzvah.  It was lovely and I truly enjoyed myself, with the exception of the thirty minutes I spent coughing!!

It is interesting.  When I lived in ---, I wanted so desperately to "fit in" and to be accepted. I have had trouble "fitting in" most of my life.  It is due, in part, to my hearing loss which rendered me at times "socially inept".  Speaking out of turn, or out of context, mis-communications or simply missing communications would do that to me.  But one would think that as an adult I would not have such problems. 

But --- is a suburb of NY and thus, in a way, part of the greater NY metropolitan area.  People in that area of NY and NJ tend to be more snobby, more clique-y.  Barry and I were very active in our community, we were founding members, literally of our shul and involved in many of the shul efforts and activities.  But, that did not buy my acceptance into that society. For the most part, I was snubbed by many of the members of the shul, in particular the "rich" people.  I saw it, felt it, but for the most part, I ignored it.  To my way of thinking, if I ignored it, I would not give it any validity or credence.  But, that did not mean I did not feel it, that did not mean I was not hurt by it. I was.  Deeply.  My late husband also saw it.  For himself he did not really care.  He had never really concerned himself with fitting in, because growing up he DID fit in, easily.  He did not have the social issues that I had growing up which later made social acceptance so important for me.   He and I did not speak of it much, he had the same attitude about validating it as I did.  But he did speak of it with his sister, Karen. She told me, after his death, that he told her how much he loved me and how it pained him to see me treated with disrespect by the snobby members of our shul.  Since Barry died and since I moved away from ---, I actually became closer to one woman there, who, like me, has been "shunned" by the snobby members of the "rich elite".  Barry and she were close when he was alive but she and I were like oil and water back then.  But now we are close. We are very alike in many ways.  I have spoken with her about this issue of my "fitting in" in ---, and she agreed with me that we have been snubbed.  So I know I am not imagining it, I have not imagined that I have been slighted. 

I moved to --- not knowing a soul and I had talked myself into "not caring" if I would be accepted or not.  Of course, it was a lie to myself because of course, I did want to be accepted. But I needed not to have worried -- I was welcomed with open arms by everyone, without reservation, without judgment, and without care for my socio-economic status. It was a totally new experience for me and I enjoyed it.  But I also considered it to be anomalous within the religious Jewish community at large.  

After living in --- for 14 months, I made aliyah to Israel and went to live in Hashmonaim.  For most of my first year here, I have not really felt a "part of the community", but just living in the midst of one.  I did not feel snubbed, I did not feel disrespected.  At times I felt disconnected or even forgotten, but not snubbed, and not disrespected.  However, I am now in my second year here and I have been noticing that I am feeling more a part of the community, in a way I had not felt before.  I find that people come up to me to converse with me and include me in their discussions.  It is very nice. 

Last night I went to the Bar Mitzvah with a certain amount of trepidation.  I knew it would be a big, fancy affair and that many of the attendees to the event would be from the wealthier people on the Yishuv.  I wondered if I would experience the same snobbery I experienced when I would attend these type events back in ---.  In ---, I would find that women would either ignore me, or talk over or around me, or more directly, titter at me.  I remember the despair I would feel when I was in those situations, especially if there were separate seating.   I knew that last night's affair would not be separate seating, but then I was also going it alone, without a spouse, so it really made no real difference to me.  In --- I would find that I would be seated with people who were the "odd ones out" rather than with my true peers.  It was very hurtful for me. 

Well, last night I arrived at the event, and the host of the party was very happy that I showed up.  There was at first a sumptuous smorgasbord and the inevitable mingling and schmoozing. I used to keep to myself during the mingling and schmoozing parts of these events.  Last night, I could not have done that had I wanted to. I found myself mingling and schmoozing, and WELCOMED into the little discussion groups that sprang up here and there throughout the hall.  It was a very nice sensation, to know that I was not being snubbed.  Then it came time to be seated at our tables. I was assigned to Table Five and wondered who I would be seated with.  I found myself seated with people I know, amongst couples rather than amongst the "odd ones out".  I was included in all the conversations, and in fact, asked to tell the story of my "amazing reunion" with Judy M - I had attended ulpan in 1977 with her and her twin sister -- I believe I wrote about this.   I was invited to sit at other tables to schmooze in between courses.  When I went through my thirty minute long bout of coughing, I was made to feel the concern of others -- for ME, and not for themselves.  A high point of the  night was when I returned to the table from the ladies room and suddenly all the women got flustered. Why?  Because they all thought I had left for the night and had given my shawl which I had left on the chair to another woman to take back home with her to give to me the next day!  It was very funny and it turned out that she had not left after all and one of the women went sprinting after her (in HEELS) to get my shawl.  I followed her and we all had a good laugh about it.  It was a laugh of inclusion and it felt SO GOOD TO ME!!

I know I am going on a bit about something that is really much ado about nothing.  But for me, after YEARS of trying to fit in and finally feeling like I do, it is not nothing, but very much a lot of something!!