Thursday, December 11, 2014

SantaCon Redux

I first posted this on my blog a year ago. William’s memorial service was December 15th, 2012.  An update seems appropriate.    

“As we emerged from William’s memorial service in Midtown Manhattan exactly a year ago, Saturday, December 15th, we were embraced by a swarm of drunken Santas. The irony of leaving the memorial for someone who died due to a substance use disorder, only to encounter the obscenity of a mob of drunken Santas, reindeer, and elves was not lost on us.  SantaCon was in full swing. 
Fortunately the New York Times has spared me having to reflect on this event.  I’m happy to say that Lee Seinfeld, the owner of my local watering hole, wants nothing to do with the event.” 

Here is an op-ed piece that captures my feelings nicely.  http://nyti.ms/1ftAsCr  Thank you Jason Gilbert.    

You can also go here to find Times reportage on the event:

Or, for that matter, try the LA Times:


This year, add this piece by Meredith Hoffman in The Village Voice:



Wednesday, October 8, 2014

The Fox Watching the Chickens

On July 9th the office of New York Attorney General Eric T. Schneiderman make the following announcement:

NEW YORK – After an investigation uncovered widespread violations of mental health parity laws by the company, Attorney General Eric T. Schneiderman today announced a settlement with New York City-based EmblemHealth, Inc., requiring the health insurer to reform its behavioral health claims review process, cover residential treatment and charge the lower, primary care co-payment for outpatient visits to mental health and substance abuse treatment providers. The settlement also requires the health insurance plan -- which has 3.4 million members in its HIP and GHI divisions -- to submit previously denied mental health and substance abuse treatment claims for independent review. That review could result in more than $31 million being returned to members wrongfully denied benefits.

An investigation by the Attorney General’s Health Care Bureau found that since at least 2011, EmblemHealth, through its behavioral health subcontractor, Value Options (My bold.), issued 64% more denials of coverage in behavioral health cases than in medical cases. The agreement with EmblemHealth is the third reached by the Attorney General’s office so far this year enforcing the mental health parity laws and stems from a broader and ongoing investigation into health insurance companies’ compliance with the laws.

For the full text of the Attorney General’s announcement – go here:

Today I wanted to learn more about Value Options.  Those that know me understand I have more than a casual interest in their performance and behavior.  The first thing I saw on their website, at the very top of the screen was an announcement about S.O.S. – Stamp Out Stigma. See for yourself here: http://stampoutstigma.com 

PLEASE correct me if you think I’m wrong.  Value Options, which has clearly demonstrated prejudice against mental health and substance use disorder claims, is now trying to pretend that it wants to end the stigma against mental health and substance use disorder, even as its actions serve to reinforce and perpetuate that stigma by denying proper claims.  The fox is watching the chickens. At the least, Value Options, should say nothing until their practice matches their “policy.”  Until then they come across as the cynical and deceitful business I believe them to be.   




Saturday, September 27, 2014

Josephine's Visit

The end of summer was sweetened by a visit from my six-month-old granddaughter, Josephine.  We’d not seen each other since Memorial Day weekend, when we were together at our Catskills home.  Josephine took her first ride on my garden tractor then, as we rode down to our lower meadow to plant a weeping willow in memory of her uncle, William. 
This recent visit was filled with firsts.  There was, of course, Josephine’s development in the interim to marvel at.  She was rolling over, sitting up, and chewing on anything and everything available to her, with an uncanny and particular fondness for all those white tags that either give washing instructions or threaten to bring the law down upon you if you remove them. Josephine’s genius for locating and deriving pleasure from those tags is unparalleled – certainly in this adoring grandfather’s eyes. 
The firsts included lots of “swimming”.  Time spent in the water:  standing while being held, or sitting in her Crab, a floating device she can sit in with holes in the bottom which allow her to kick her legs to her little heart’s content.  And kick she did.  “Kick, kick, kick”, became a refrain from parents and grandparents alike.  Josephine’s firsts included saltwater (Long Island Sound and Great Peconic Bay) and freshwater (The Beaverkill River and a nearby pond).  She and the Crab were already veterans when it came to swimming pools. Josephine is a water baby.  From her bath or shower to the cold of the river, she delights in all the sensation water has to offer.  
There were food firsts, “solids” to taste and smear:  sweet potato, pear, carrots from grandfather’s garden (happily prepared by grandfather himself).  Then firsts from nature.  She saw her first black bear and her first bald eagle, both at relatively close range.  Things adults forget to take in:  bare feet in wet grass, the captivating magic of a breeze moving leaves in the trees back and forth, the mystery of one’s feet disappearing in sand as gentle waves wash up and fall back at water’s edge. 
The permanence of things had become an issue of some concern to Josephine.  Properly so in terms of her development.  She delighted in peek-a-boo games.  Wondered what happened to a dropped toy.  More to the point was growing apprehension over the disappearance or absence of her mother.  We adults consulted Selma Freiberg’s The Magic Years or other resources on separation anxiety.  Josephine would fret or cry whenever her mother’s disappearance compelled her.  There were times when all the snuggling, hugging and kissing by her grandfather simply wouldn’t suffice. 
On our last day in the country Grandfather’s company was sufficient, however.  At least for a spell, while the rest of the adults packed for returns to New York City and Chicago respectively.  Josephine and I took a walk outside, around the house.  There was a slight breeze, just enough to move the trees and flowers and make the fine hair that gives Josephine the appearance of having a Mohawk stand up just a bit. 
I held her while we circled the house together.  We smelled the sweet clethra and the spiky cleome.  We crunched the thyme, some of it still purple, on our rock steps. We stopped by the coreopsis, looked at butterflies in the bee balm, made sure the deer hadn’t eaten Black-eyed-Susan’s or daisies or silver mound.  We put our feet in the damp grass and looked at William’s willow.  The goldenrod swayed as we came back to the front of the house and plucked a small yellow flower from the potentilla to put in Josephine’s hair.  Balance on her head is what we settled for, just long enough to share with her Mommy and GranMarg. 
A day later we were at JFK, Mommy Elizabeth strapping a baby carrier in front of her, being helped into a backpack, grabbing a purse and a suitcase.  I held Josephine, the last addition to Elizabeth’s load to carry into the terminal, while tears streamed down below my sunglasses.  For two weeks I’d done my best to console Josephine when she felt abandoned or fearful.  Now it was my turn.  William is more than a willow.  He’s a dead son who heightens my apprehension about the rest of my family.  I told Josephine she had the best mommy in the world, told Elizabeth Josephine was the best baby in the world, handed off Josephine, hugged them both and cried as I watched them disappear into the terminal.  For Josephine separation anxiety may be a “stage” she passes through.  Who knows about grandfather?       


 
Josephine with her Dad Johnny Anderes.  Beaverkill Falls 8/31/14. Where she saw her first bald eagle. 


Sunday, July 13, 2014

Birthday Trout

I got to celebrate my birthday at our home in the Catskills, near the headwaters of the Beaverkill River.  I like to say it is as close to heaven as I’ll probably get.  July 12th’s day near heaven included helping my good friend Rudi Stahl cut up and remove a storm damaged tree, putting mulch on blueberry bushes before fencing them in to help keep foraging creatures away, harvesting a banner onion crop from the garden, and turning over the beds in preparation for planting late season lettuce and spinach.
Later in the day Margot invited all the Stahls to join us for an early evening drink on our porch.  Nancy and Frederica drove over and joined us just as the Netherlands was finishing off Brazil in the World Cup consolation game.  Rudi was on his way, having decided to take a hike on the trail that passes by both the Stahl’s house and ours. 
Rudi arrived with a story to tell (always a good sign yet another gathering will be enjoyable).  He began with a wildlife report.  On his way over he’d seen two deer, one turkey, one bear,  and...could we guess…a trout!  The deer and the turkey were unremarkable.  The bear, one of several making more frequent appearances in the neighborhood, immediately invited discussion of other bear sightings, bear shooshing technique (including a stand up demonstration by Nancy), and the reminder that the ripening blueberries at both homes will ensure more bear sightings, fencing or no. 
Then to the trout.  Our homes sit on wooded hillside, pocketed with meadows, that slopes down to the Beaverkill.  There are any number of rivulets, rills and little creeks that all lead down to the river.  Some are natural, others man made drainage to help keep trails from washing out.  Many times they are dry and rock filled.  After a spring and summer of rain, sometimes heavy storms, they trickle and sing on their way downhill – feeding the Beaverkill and quickly turning it from a mountain stream to a river over the course of its 28 mile length.  A river famous for its trout fishing. 
The trout.  Rudi’s trout, he told us, was in a puddle, one couldn’t even call it a pool, in one of these tiny tributaries.  A brook trout, nearly a foot long, splashing about in just enough water to survive, easily a quarter of a mile uphill from the river.  Had it managed to somehow swim upstream (up rivulet) during flooding from one of our recent heavy thunderstorms?  Miraculous, if so.  Nonetheless, there was the trout undeniably stranded in its own tiny pool. 
Discussion on the trout’s fate ensued.  Left alone it would expire with the inevitable drying out of the pool. Unless, the thunderstorm that threatened our party on the porch and drove us inside briefly provided enough water for a partial stay of the fish’s demise.  Would a bear find it and make a quick meal?  Should we get it?  Fresh mountainside trout for my birthday dinner?  Brief speculation on how to best dispatch the fish once scooped from its modest confines in order to prepare it for dinner.  Somehow my position as birthday boy gave me some deferential authority in our decision making.  What did Bill want to do?    
None of us were really happy with human consumption as a resolution for the Brookie’s dilemma. Had he been properly fished out of the river, perhaps a different story.  Scooped from a puddle?  It didn’t seem right.  Finally, it was agreed.  We filled a 5-gallon bucket with water and the party followed Rudi down the trail to the spot where there was, undeniably and improbably, a trout.  Finding the fish seemed about as likely as sighting a troll underneath the bridge just below us on the trail. We’ve always called it The Troll Bridge.  But our party was prepared this time for trout, not trolls.  We warmed to the task.  Rudi set a large rock to dam one end of the puddle and bar a damaging escape attempt.  He tried an Austrian one-hand grab, but this trout was far too wily for that technique. A second bucket was deployed.  Dip and scoop yielded no better than Austrian hand grab.  Finally Rudi set the bucket at one end of the pool.  The trout headed toward the other end. Fredrica reported on the trout’s whereabouts.  With an inattentive moment the fish headed to the other end of its tiny enclave, Rica gave the signal, Rudi scooped, and suddenly there was much flopping, cheering, and a trout newly arrived in a fresh bucket of water. 
An excited collection of fisher-people trooped back to the house and to our cars.  The trout took what one might presume was its one and only car ride.  Our two vehicle caravan drove down to the river.  We parked and went to the water’s edge.  As Birthday Boy, I had the honor of spilling the lucky trout back into the river.  A tip of the bucket and the brook trout was in its proper element, slicing upstream with reassuring speed that let us know it was happy and healthy, unaware of our celebratory clapping.

Neither the Brookie nor I know what the next year will bring.  I doubt the fish has thought about it very much.  I, not much more.  But for each of us, the first day was glorious.  I stood next to Nancy as we lingered at river’s edge, looking upstream.  It is a beautiful spot.  Early evening, the water shimmering as it cascades over rocks, providing proper hiding pools for a fish and reminding me that indeed, our home in the Beaverkill Valley may well be as close to heaven as I’ll ever get. If I do get closer, it’s hard to imagine it being any better.   
  



Saturday, April 12, 2014

REMARKS TO THE CLASS OF 2017, COLUMBIA UNIVERSITY COLLEGE OF PHYSICIANS AND SURGEONS


In December of 2012, following his death due to acute heroin intoxication, we made an anatomical donation of our son William’s body to Columbia University’s College of Physicians and Surgeons.  On April 9th, 2014 we returned to Columbia for a ceremony conducted by the members of the class of 2017, first year medical students.  They had just finished their work in the anatomy lab.  They led a beautiful, reverent, elegant service that honored their first patients, those whose bodies began them on their career path. Family members had the opportunity to address the class, their faculty, and other families. Here is what I had to say.
 

We are here today to celebrate your good work, and the life of our son, brother, nephew, uncle, and friend:  William Head Williams.   We are particularly grateful that William’s sister – Elizabeth Hope Williams, and his seven-week-old niece (who will only know him through story and photographs)  Josephine Hope Anderes – made the trip from Chicago to be with us.
Nearly 80 years ago Josephine’s great, great uncle, Brockie, died from a disease which would have been cured by penicillin a few short years later.  Nearly 60 years ago Josephine’s great uncle, Tony, died from polio, in 1955, shortly after the announcement of the Salk vaccine.
Josephine’s uncle William, died from substance use disorder, from an accidental heroin overdose, in 2012.  At William’s memorial service his mother, sister and I made the following pledge:  “We promise to do everything in our power to educate and inform people about drug abuse and its prevention, to provide ever more enlightened treatment for addicts, to help make treatment options for addicts more readily available, and to remove the stain of shame surrounding this disease.” 
Part of honoring that pledge brought William to you.  Part of honoring that pledge brings us to you today. William was a peer of yours, just turned 24 when he died.   William was but one of the victims of the plague of our time:  opiate addiction.  We are, indeed, in the midst of an epidemic.  Data, like much else in the treatment of substance use disorder, is slow to arrive.  However, we do know that overall, annual overdose deaths from pills and heroin now exceed automobile deaths in this country.  Every day, 105 people die of drug and alcohol overdoses in this country.  While the latest data is from 2010, it is most likely that the number of drug deaths in 2014 exceeds the number of deaths at the height of the AIDS epidemic.

As you continue forward in your careers - professors, practitioners, and students alike, we urge you to consider the following, our hope for the future Josephine will live in. 

·      A time when an individual can say, “I have a substance use disorder,” without judgment or censure. When family members can stand beside the afflicted and say without shame and stigma “…and we are all getting counseling and support to aid in our loved one’s recovery.”

·      A time when substance use disorder is recognized by laymen and professionals alike as a brain disease.

·      A time when research for substance use disorder will be on a par with that for heart disease, cancer, and diabetes.

·      A time when people with substance abuse disorder are treated with the same compassion and understanding, treated with the same urgency, accorded the same dignity, as any other patient with any other medical or surgical need.

·      A time when physicians, not health insurers, practice addiction medicine, when physicians, not actuaries, determine the best course of treatment.

·      A time, not in the future, but now, when physicians are trained to recognize and treat substance use disorder in medical school with the same rigor given to any other disease. 

·      A time when physicians in any specialty can recognize, treat, or refer patients to a proper source of treatment. 

·      A time when there are sufficient numbers of physicians board certified in addiction medicine.

·      A time when opioid prescriptions are written responsibly and properly controlled.    

·      A time when we stop pretending will power is a cure for a neurological problem.  Will power needs to be exercised, not by the afflicted, but by policy makers who can help change the course of this epidemic.

 23.5 million Americans suffer from substance use disorder.  Currently a mere 10% are properly diagnosed and treated.  100 million family members also share in this family disease.  Doubtless some of you are among that 100 million.  It is not inconceivable that 10% of you, as in the population at large, will have a personal battle with this disease. 

We promise to do our part to engage insurers and lawmakers vigorously and relentlessly until they have done their part. Just last Friday we spoke before a Congressional caucus with much the same message we share with you today, encouraging them to embrace rapid change. We ask you, as scientists and healers to think seriously about what you can do, now and in the tomorrows to come.  That is work we cannot do.  We leave it to you.  We’ll share with you the burden of removing shame and stigma from this disease. 

This is our hope.  A hope that early in baby Josephine’s life, another disease can be overcome by the courage, imagination, and talent you all share.   A hope that will live in our lives and yours, not by name alone, but by action.

In another time, in a better era, William might have entered the College of Physicians and Surgeons with you.  Not as a cadaver, but as a gifted and talented young man, prepared as you are, to serve others.

We ask you as a body to summon the will power to make these hopes and possibilities realities.

 We WILL prevail. 

Thank you.  


  




Sunday, April 6, 2014

HOUSE CAUCUS ON ADDICTION, TREATMENT, AND RECOVERY

On Friday, April 4th, Margot and I spoke at a briefing held by the House Caucus on Addiction, Treatment, and Recovery.  We are grateful to Congressmen Ryan, Fleming, and Tonko for holding this important discussion.  The texts of our presentations are below.  We can only hope this appearance sparks more discussion and awareness everywhere.
Margot Head to House Caucus on Addiction, Treatment and Recovery
                                                                                                        April 4, 2012
Health insurance companies are killing our children; I use children in the sense that everyone, regardless of age, is the child of someone.  And the understudies to the killer insurance companies are the hospitals and the so-called rehab places.
Our 24 year old son William had a substance use disorder; or as the population at large would say, “He was an addict”. In this case a heroin addict.  His case happened not to be related to prescription opioids..plain street heroin in the little plastic glassine bags.
William had had at least 15 overdoses in 2012 and 19 emergency transports to hospitals in 2012.  In October of that year William succumbed to a final and ultimately fatal overdose.  Following that overdose William spent six weeks in a NYC hospital until it was absolutely confirmed that he would never wake up and was consigned to a “persistent vegetative state”. William’s brain had been deprived of oxygen for too long in that overdose.
Here’s what else:  4 days prior to that last overdose William had gone to the chemical dependency unit of another  hospital and asked to be admitted for INpatient detoxification..The lab work at that particular hospital gave Will the diagnosis of 304.80 which means polysubstance dependence. In our son’s case polysubstance meant heroin and Benzodiazepines.  Our son’s other substances were marijuana and alcohol; all of these drugs are “downers”…in his case anxiety –palliatives.  There can be no doubt that William was self- medicating.
Back to the request for INpatient detox at this one hospital. William spent hours there waiting for pre approval from his insurance company. Despite William’s DX of polysubstance abuse, some functionary at insurance, who probably didn’t know how to read, or interpret records, DENIED William authorization for INpatient detox, and would only approve outpatient methadone maintenance.  Will  had already flunked at least 4 outpatient rehabs/detoxes. He declined their offer of oupatient methadone maintenance. William knew methadone is harder to get off of than heroin and  I suspect that he knew that this outpatient bit was killing him.  I did NOT know these health insurance companies had a license to practice medicine.
When the hospital found out it was not going to get paid, it sent William to a public hospital to get detox. William ‘yessed’ them, left and called his dealer; we know that from his cell phone record. He got high and came home 10 hours with heroin raccoon eyes..big black circles.  I have heard a rule that if an addict requests help, the help has to be done in  the moment, not 2 seconds, minutes, hours, days or months  later.  Substance abuser’s brains are hijacked by the craving for their drug or drugs.
One other true story: A mere 6 hours before William requested that denied INpatient detox, he had been released from another hospital emergency room. The attending doctor at that hospital wrote, “I do believe patient is at risk of overdosing on heroin, however he does not meet criteria for involuntary psychiatric hospitalization and rather should pursue inpatient rehab which he is refusing. Discharged from ER. Axis 1 Opioid dependence.”
One more similar narrative, of many, is that one month before all of the above happened, William had been in yet a different emergency room. A wise and experienced doctor wrote on his records that he “was a danger to himself and others” and told me on the phone that he should be detained against his will.  The young ATTENDING physician released him anyway. William , I and his dad had a meeting w/ this doctor prior to the discharge; we think he knew nothing about addiction.
And the only reason I have a lot of the above information is that I had to get a court order to obtain records.  I also know that insurance paid hundreds of thousands of dollars on our son and was billed in the area of half a million. It certainly was good they saved money on that INpatient detox.

Bill Williams’ Presentation to House Caucus on Addiction Treatment and Recovery  4/4/14
In early December of 2012 our son, William, entered Columbia University’s College of Physicians and Surgeons at the age of 24.  His arrival there was off the beaten track, beginning with visits to a psychotherapist. Over the next two years stops on the way included an addiction psychiatrist, out-patient treatment, treatment with Suboxone, in-patient detox, in-patient treatment, out-patient treatment, out-patient detox, treatment with Vivitrol, more out-patient treatment, another in-patient treatment, more out-patient treatment, a revolving door of well over a dozen trips to and from the emergency rooms of at least four different hospitals, an attempt to work with another addiction psychiatrist, Alcoholics Anonymous, Narcotics Anonymous, and a home life fraught with tension and despair, sometimes hopeful during intermittent periods of sobriety, and always filled with the apprehension of misfortune.
His credentials for Columbia were unorthodox, “acute and chronic substance abuse” which caused “complications of acute heroin intoxication”.  William was admitted, not as a medical student, but as an anatomical donation. A cadaver.  His credentials came from his death certificate, not any academic transcript.  
As a result of his acute intoxication, when his heart stopped beating for too long, when he was hospitalized for six weeks until it became clear that William had withered to a vegetative state, we made the decision to remove him from life support and have him become an organ donor.  Organ donation for someone in a vegetative state requires an expedient demise.  William did not expire within the necessary one-hour time frame, though his mother, sister and I were with him in the operating room, telling him he could let go.  Rather, he lasted another 21 hours before drawing his last breath in our arms.
Determined that his death not be in vain, his mother, sister and I made the following pledge:  “We promise to do everything in our power to educate and inform people about drug abuse and its prevention, to provide ever more enlightened treatment for addicts, to help make treatment options for addicts more readily available, and to remove the stain of shame surrounding this disease.”  A very first step to honor that pledge was the anatomical donation of William’s body.  We continue to honor that pledge by appearing before you today.
Shortly after we were invited to appear at this briefing we received another invitation.  William’s contribution at Columbia has reached an end.  This coming Wednesday his family, including his seven week old niece who will only know him by story and photographs, has been invited to a ceremony at Columbia honoring those whose bodies helped train and educate this year’s class of medical students.  We will meet and hear from these medical students, their professors, and other families who have donated kin.  We will have an opportunity to speak to them.  What we say to them will differ little from what we say to you today, which is to say that ignorance about substance use disorder remains the order of the day. It is the plague of our time.  Anything we say that is repetition bears repetition until it manifests itself as policy change and practice of substance and consequence.
Parity is about more than receiving equal health care insurance for substance use disorder and mental health issues.
·      Parity means an individual can say, “I have a substance use disorder,” without discrimination, judgment or censure.  Parity is when family members can stand beside the afflicted and say, “…and we are all getting counseling and support to aid in our loved one’s recovery.”

·      Parity means that substance use disorder is recognized by laymen and professionals alike as a brain disease.

·      Parity means that funding for research for substance use disorder is on the same level as that for heart disease, cancer, or diabetes.

·      Parity means that people with substance abuse disorder are treated with the same compassion and understanding, treated with the same urgency, accorded the same dignity, as any other patient with any other medical or surgical need. 

·      Parity is when physicians, not health insurers practice addiction medicine, when physicians, not actuaries determine the best course of treatment.

·      Parity is when physicians are trained to recognize and treat substance use disorder in medical school with the same rigor given to any other disease. 

·      Parity will be when physicians in any specialty can recognize, treat, or refer patients to a proper source of treatment. 

·      Parity will be when there are sufficient numbers of physicians board certified in addiction medicine.

·      Parity will become practice when more than a mere 10% of the 23 million plus Americans who suffer from substance abuse disorder are properly diagnosed and treated.

·      Parity will come about when rehabilitation facilities have medical doctors on staff, all the time.

·      Parity is when physicians, politicians, school principals, police and parents all realize that not only are they responsible for helping to treat this disease, but also that they and their families are as susceptible as anyone else to being afflicted by the disease.

·      Parity will arrive when we stop pretending will power is a cure for a neurological problem.  Will power needs to be exercised, not by the afflicted, but by policy makers who can help change the course of this epidemic.

We are, indeed, in the midst of an epidemic.  Data, like much else in the treatment of substance use disorder, is slow to arrive.  However, we do know that overall, overdose deaths from pills and heroin now exceed automobile deaths in this country.  Every day, 105 people die of drug and alcohol overdoses in this country.  While the latest data is from 2010, it is most likely that the number of drug deaths in 2014 exceeds the number of deaths at the height of the AIDS epidemic. 

William’s cause of death could have been listed as “Institutional Indifference”.  Failed insurance, clumsy coordination between health care providers, and antiquated treatment practices doomed him. 

In another time, in a better era, William might have entered the College of Physicians and Surgeons, not as a cadaver, but as a gifted and talented young man, prepared to serve others. 

We ask you as a body to summon the will power to make these possibilities realities.

 We WILL prevail.

Thank you.