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STAY SAFE

 

Sunday, June 12:

As a parent, you look at that little being God has placed in your life and with everything you have, you swear to protect it.  That passion becomes the constant thrum behind everything you do and everything you say.  A second heartbeat as reliable and steady and strong as the one that keeps your blood pumping. 

Today more than a hundred parents faced their worst nightmare, and many of our beautiful children lost their lives.

Why does this one hurt me deeper than the other shootings?  I tell my son it’s because I have “my” LGBT children whom I have care for all these years. I tell my husband it’s because I spent so many nights, before I met him, dancing and laughing and drinking at nightclubs with the waiters from the restaurant in the wee small hours after we got off work each weekend. I tell my mother it’s because I am the oldest, raised to physically stand in front of those younger and smaller than me so I can protect them.  But only my daughter sees through me to the core and knows.  I will, for as long as I live, be a mother who hears that imaginary bullet whine across the room towards her child and knows that there is nothing at all I can do to stop it.

This one cuts to the bone because when it comes down to it we are rarely there when we’re needed.  We make such big promises and even as we make them, we know they will go unfulfilled.   We weren’t at the door to tell the shooter no and take the gun from his hands.  We weren’t there to cradle those who made it out and look back in fear.  We don’t wait at home for the first responders, to rub their backs as they relive the nightmares.  And we won’t hold the hands of those bereaved loved ones as they take the first fragile steps into their new reality.

“Stay safe”, we breathe to our infants, whispering the words into ears as tiny and opalescent as a shell.  “Wear your swimmies”, we tell our toddlers, cramming pudgy arms into the inflated rings.  “Wear your helmet”, we lecture our schoolchildren, tightening the buckles under those soft chins.  “Wear your seatbelt”, we remind the teens as we hand them the keys and watch them swagger out the door.

But this, this is something we don’t have a magic charm for.  How do you stay safe against hate, against misguided religious fervor, against the cruelty of children to immigrant schoolmates and of older folks railing against change.  How do you stay safe against words and bullets, guns and fists, lies and anger.  These are not new weapons.  There have been massacres as long as mankind has had the power to kill.  These are not new fears.  People die the world over from these selfsame actions and have done so for as long as we’ve had history.

So I will tell myself, and my children, my mother and husband and friends, we can’t stay safe.  That isn’t working.  Instead, let’s wear our hearts openly and in public.  Stand up like my Godson and tell your teammates those “jokes” are not okay.  Send an email, like the head of the prayer chain at church, that reminds us all that we are a faith that is inclusive, not exclusive, and that God is not an emissary of hate.  Reach out, like my daughter, to remind people that guns kill, that mental illness kills, and that each of us has a duty to make sure there is less of both in the world each day.  Wear your individuality and grace with pride, like my “adopted” sons.  Have the courage to put out your hand to protect a pet, a child, or someone more helpless than you.

So today, even as I send the impossible plea “stay safe” to the young people in my life, I promise those who didn’t that I will remember, today and every day, to wear my heart on the outside.  That it is my job, and all of ours, to be kind and brave and good.  That is all we have against the dark, and we must all use it so that someday, somewhere, someone will make the difference that matters.


TELEMEDICINE AND THE MEDICAID DILEMMA

 

Saturday, June 4:

We are a technology-dependent society.  We use our smart phones, tablets, and other devices to quickly and easily access information, engage in financial transactions, and perform vital job functions. Healthcare providers have used advances in technology to enhance patient care.  A doctor at a huge metropolitan hospital in an urban area can now see and treat, in real time, a patient at a rural site hundreds of miles away.  In a miracle of modern medicine, even patients in remote areas can thereby receive cutting edge treatments.

But there is a problem.  As the applications of technology and the skills of its users advance, the payment system sometimes fails to keep up.  While many states have laws providing that telemedicine should be paid for just like face-to-face services, because that is essentially what telemedicine is, some payors don’t yet have codes that cover these services. 

Changing Medicaid reimbursement and updating Medicaid fee schedules has been likened to turning the Titanic.  Provider skills and the practice of medicine advance quickly, driven by patient needs and the available tools.  Patient care does not suffer, because providers are quick to use new abilities to better treat people.  Rather, it is the providers who suffer.  A doctor is unwilling to require a fragile patient to leave her home and drive hours to the hospital for a required check-in visit when she can simply use a smartphone or computer to best treat her.  So the doctor does what is best for her patient, and simply goes unreimbursed for those services.  That is not the intent of the law, and it shouldn’t happen.

In 2015 the Center for Medicare & Medicaid Services (CMS) added seven new telemedicine billing codes to the physician fee schedule. The new codes include those for prolonged office visits, psychotherapy, and annual wellness visits. The CMS has also added a new Current Procedural Terminology (CPT) service code, 99490 for chronic care patient management in the final rule. This code is not a telehealth code and it can be bundled with the existing CPT code 99091 for collecting and reviewing patient data that does not require the beneficiary to be present; though, the CMS will still not allow any additional payments for this service.

While CMS has expanded Medicare coverage for telemedicine as long as the services are provided in a hospital or SNF setting, see: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdfstate Medicaid coverage has not always kept up with these changes.  And even CMS won’t pay for direct to patient services, where the patient is at a location other than a hospital.

Telehealth treats patients in real time, where they are located.  That is simply good medicine.  We need to work with payors, particularly state Medicaid departments, to make sure that providers can be paid for all the work they do and that codes exist to make this possible.  That’s the best way to keep medicine moving forward, particularly for our state’s most vulnerable citizens, the Medicaid and Medicare population.


KEENELAND

 

Friday, May 6

 

My son and I played hooky one morning and went to see the horses work at Keeneland.  There were maybe 20 visitors on the entire grounds.  We wandered through the paddocks and saw horses learning how to walk in the warm-up ring and then through the tunnel onto the track.  The sun was rising, planes were taking off in the distance, and a million chirping birds flew to and fro.

Then we stood on the rail for a couple of hours and saw dozens of horses go through their various workouts, from the nervous two year olds jigging around with experienced exercise riders and ponies, to the high dollar stakes horses being timed in a flat-out gallop.  We saw some gorgeous horses and some really, really fast works.  Lawson had his stopwatch and timed a few.  Some of the fanciest sprinters do their real works on the far side, so you can't time them, but many hit their fasted speed so they end at the finish line in front of the grandstands, which is incredibly cool.

Many of the riders talk or sing to their horses.  English, Spanish, French – we heard it all.  Whispers of encouragement to a horse that thinks it has hit top speed.  Lullabies to soothe fractious colts.  Chortles and whistles and clucks galore.  The track is a noisy place.  You never expect to hear exercise riders, galloping three astride, to be talking to each other about dates, friends and musing on life as if they were out for a quiet stroll.  That really surprised me.

Then we wandered past the barns, watching horses be bathed, groomed, tacked, fed, or even being ridden through the aisles for exercise.  My favorite was a stable washing three horses at a time.  They had it down to an art, arcing the hose across backs and sponging legs in quick succession.

Next we made a pit stop at the track kitchen to have enormous bacon and egg sandwiches with a rotating crew of jockeys, trainers and owners.  Even my jaded son was pretty impressed.

Left the house at 6 a.m., was home by 9:30 and at a desk in lawyer clothes by 10, nobody the wiser.

It was truly incredible.  We are definitely doing this again.  No entrance fee, nobody around, just you, the horses, and the people who work with them.  Unbelievably wonderful.

If you all are ever in Lexington overnight, it is totally worth getting up early to do this.  Keeneland is a state treasure and this was just so peaceful and exciting, both at once.

ELECTION LAW CASES

 

Saturday, May 14:

When you think of the lawsuits that decide whether a candidate for public office is qualified under the terms outlined in state law, you probably envision those cases taking place in front of cameras in one of the fancy new courtrooms in one of the state’s biggest cities.  Maybe in Louisville in the imposing Justice Center, in front of a judge we have all seen on the news before.  And that is what I planned for the most recent candidate qualification case I handled.  Jefferson Circuit Court, media ready to come watch, local concerned citizens attending and giving input.

But in fact, the case was transferred to a small regional courtroom.  The judge is better known for being informal and decisive than for her TV appearances.  The courtroom is so old that the ten-foot-tall windows still had original glass, wavy now with years of temperature changes so that the view of the small town outside was slightly distorted, as if reflected in a wading pool.  The air conditioner in the hall was off, a paper sign stating simply “broke”, taped to it.  Outside the district court clerk’s office, a young mother handed a toddler a can of pop, and a man with a pomaded coif read the paper.  This could have been any courthouse in any Kentucky town at any time in the past five decades.

I had a hard time determining which of the four historic buildings in the town square actually housed the courtrooms.  Every building was open to the public.  Each of them had a desk downstairs where a sheriff’s deputy or two kept an eye on those coming and going.  An older gentlemen sat at the entrance, chewing tobacco meditatively and looking down. People hurried in and out, on court business, or registering cars or taking papers to various offices.  Some of the doors were slow to close and a breeze scented with the blooming trees outside crept in, softly flavoring the air.

It was time to start.  And so we sat at the bench, five dressed up lawyers, two serious clients, and some witnesses.  We waited for the hearing to begin.  I am antsy before every hearing, jiggling my foot and lining my pink folders of papers up, just so, over and over.  Opposing counsel puffed up his chest, made a neat note on his legal pad, and slapped down an imposing file of case law.  We both thought we were so important and we were so full of desire to fight and to win.

The judge came in, sat down, and began to speak.  Her voice trembled with passion and sincerity.  This is a serious case, she reminded us, and our job here is also important.  Voter rights means a lot to me.  Candidates who want to serve the public are the bedrock of our communities.  We change lives with these decisions.

And in that moment, the focus changed.  This wasn’t, “Hey, that guy has more case law than I do.”  It wasn’t, “Take that, I’m now the only valid candidate.”  It was, instead, “We are all on a mission, and that mission is to make sure that, to the extent possible in the lives of we flawed humans, we are doing the right thing in the eyes of the law and in the eyes of the public.”  The judge was right – this was an significant case for that important reason.  We are so lucky to be able to run for office freely and without fear.  We are so blessed to be able to speak our minds in politics and to vote our hearts at will.  We forget what an incredible gift this is and that not every citizen of the world has these same opportunities. When you go to the polls next Tuesday, take a moment to thank everyone who made this possible for you.  This is, as that wise judge reminded us, an important job.