25 August 2010 Treat the patient, not the chart

Or at least read the damned chart before not treating the patient.

I could have predicted this. In fact, I did predict it.

In mid July, the schedule used by VA to control ordering and tracking of meds combined with the delivery schedules of the US Postal Service to provide me with two unopened containers of tracked meds plus about 2-3 days in an opened container the day before I had a scheduled appointment. I’m required to bring in meds for pill counts at visits with my primary care provider. I had discussed this situation with her at my last visit in January. So, of course, on 15 July I carried my meds and my concerns into Johnson City.

The ordering schedules are established and enforced by some oversight committee. The required re-order frequency is to phone in for renewal 21 days after receiving a shipment. I’m a retired clinical lab scientist. I am, by profession, mildly obsessive-compulsive. I don’t miss medication doses and don’t miss scheduled renewal times.

My primary care physician suggested that I not renew at the next 21 day interval and let the problem self-correct. I waited an additional two weeks, making it a 37 day interval between my last shipment’s arrival and my re-order.

Yesterday afternoon my cell phone rang, unusual in and of itself. Before I could get to it my provider’s office nurse left voicemail telling me to call a VA extension for message from my provider. The message indicated that I am believed to have 2 shipments on hand and do not need to re-order at this point. Exactly what I was afraid would happen. I’ve followed every guideline, every legality, and now I’m likely to be skewered by a provider who noted what I would do in her chart but has not seemed to follow up on what she charted.

I’ve spent the better part of two hours on hold or talking with various clerks and RN’s while trying to clear up the misconception that I have more meds than I do. Of course, the layers of access and triage keep me from speaking with the two people I need to speak with most, my provider and her office nurse. The way the system is configured, there is no way I could have re-ordered my meds as required and not wind up with an excess amount on hand. If I don’t re-order on time I can be considered in violation of my medication agreement with VA.

I’ve spoken with two triage desk RNs this morning, trying to make it clear to them that I need to speak with my physician and that I no longer have the two shipments I had on 15 July. I’ll wait out the afternoon, hoping that she understands that I need to speak with her. She doesn’t really want to talk to me by phone if she can avoid it.

I use VA for healthcare for two reasons. First, I’m entitled to it. I earned it and I see no reason not to call in that claim. And reason two is affordability. Even if I could find a competent and capable physician willing to accept another patient with no insurance but Medicare, the out of pocket expenses would be too great. If I left the VA system my medications costs would double what we’re currently paying per month for meds.

By and large, I’ve received relatively good care from VA. The system is overloaded, underfunded, understaffed in many areas. The bulk of its employees want to provide quality care for veterans. But when something like this happens the built in redundancy, inescapable delay, and bone-shattering annoyance at being unable to deal with the right person when a problem first arises can make the nature of the system an unwitting obstacle to quality.

Congress needs to fund the VA system at a much higher level. There are millions of vets who rely upon it for all their health care. I want to be able to trust my providers, not cringe at the thought of dealing with a feudalistic structure.

There’s an additional facet to the overall clusterfuck. The relief mail carrier, who covers weekends and some Fridays and Mondays, has repeatedly not made any attempt to deliver medication packages that require signatures. He has failed to attempt delivery. He just drops off a notice that a certified package can be picked up the next day at the branch post office. If this happens on the day before a holiday weekend, that package, my meds, can sit in the branch 4-5 days before the regular carrier returns and delivers the mail as he is supposed to deliver it. So I need to make my physician aware of the possible delay in receipt if she waits too long to renew my meds. We’ve complained to the Postmaster but he can’t guarantee the timely delivery if he’s dealing with someone who will sign the package out but not attempt delivery intentionally.

I’ve made all the calls I can make today. I’ll be surprised if I hear from anyone else this afternoon. At least, the problem became apparent in midweek, not Friday afternoon.