Archive for the ‘Health’ category

Climate change, home, and mental health

March 12, 2019

I’ve been thinking about home recently. The land I grew up on is still there, but the home is gone, replaced by a house that overwhelms the land. Though I didn’t live there anymore, it still makes me feel a sense of loss whenever I’m in the neighborhood.

And how much stronger would that sense of loss be if the land were gone?

The 2018 “Sea Level Rise and Climate Change” Final White Paper, prepared by the University of Hawai‘i Sea Grant College Program, is an alarming summary of the effects of climate change on Hawaii’s environment, communities, and overall well-being.

There are environmental impacts, like more frequent heat waves, worsening air and water quality, rising sea levels, changes in rainfall patterns, changing ecosystems, and more frequent weather effects.

There are corresponding health impacts, like increased respiratory illness, heatstroke, and cardiovascular and kidney disease. And climate change impacts us as neighborhoods and communities, like our ability to travel within and without the islands and our access to food and freshwater.

Beyond the environment and our physical survival, climate change affects our mental health.

How can we thrive with the threat of displacement, the threat of losing our homes and our connection to the ‘aina? How can we address mental health concerns in our disaster planning and community resilience efforts?

In 2018, 700 homes on Hawaii Island were destroyed during the Kilauea eruption, and over 2,000 people had registered to receive aid from the Federal Emergency Management Agency (FEMA), according to Pacific Business News (7/9/18).

Also in 2018, more than 100 people lost their lives, and over 17,000 homes were destroyed by California wildfires, according to the California Department of Forestry and Fire Protection, reported The Weather Channel (3/11/19).

As small Pacific island nations become inhabitable due to sea level rise, lack of fresh water, or other factors, an increasing number of climate change migrants may come to Hawaii because it is similar to the home they left behind. How can we help them thrive in Hawaii? What can we learn from their experiences with the loss of place and loss of their connection to the past?

I’m feeling a little nostalgic about my childhood home. What are your thoughts about maintaining or regaining mental well-being in the face of losing a home?

How connected do you feel to your home? Do you live in a flood or tsunami zone? Are you prepared for a sudden disaster or a slow rise in sea level?


Practicing gratitude at the airport

November 6, 2018

When I was young, family and friends walked us to the airport gate and waved goodbye. When we returned, they met us at the gate with flower lei and hugs.

Today, to pass airport security, we carefully measure liquid toiletries, stand in line like cattle, open our bags for inspection, and take off our shoes. We walk through full-body scanners and are subject to random searches.

All of this doesn’t make me feel safer or welcome. It made me feel like a criminal before I even reach the airport gate – anxious, stressed, and powerless.

But after participating in an online course, “The Science of Happiness,” for a few weeks, I realized that I didn’t have to feel that way. While I don’t have the power to change the Transportation Security Administration (TSA) procedures, I can change how I react to them.

I have the power to change my attitude.

I can acknowledge that there is a positive outcome for me personally by going through airport security. I can appreciate that TSA representatives are trying to act in my best interests.

So the next time I had to go to the airport, I tried to put myself in a grateful mindset.

Grateful that TSA is working hard to keep us safe in airports.

Grateful that TSA is professional, competent, and courteous.

Grateful that we pass through security with rules and rights.

Grateful that we have clean, air-conditioned check-points.

Grateful that all of my belongings are returned to me intact.

Grateful that we have the privilege to fly by airplane.

On my last trip, I thought about the things I was grateful for. I felt calmer as I approached the security check-point. I was able to breathe easier and felt less anxious.

By changing my mindset to one of gratitude, I had a more relaxed and pleasant airport experience.

How often do you travel by airplane? How would you describe your experiences with airport security? What can you do to improve those experiences?

Health insurance hunter: secondary claims

May 15, 2018

I work for a small nonprofit organization in Hawaii, and it was eye-opening to enter the mysterious world of health insurance coding and billing. I gained a new appreciation for my doctor (aka primary care physician), my son’s pediatrician, my dentist, and my optometrist.

Earlier this year, I shared some stories about the sometimes confusing and frustrating health insurance claims process. But it doesn’t end there.

Some people have multiple health insurance policies. These secondary claims are tricky. The secondary plans often, but not always, pay the copayment or coinsurance (aka the “patient’s responsibility”). The secondary plans sometimes, but not always, pay for services that the primary plan does not cover.

Healthcare providers have to verify which insurance is primary. We have to verify which claims are forwarded (“crossover”) automatically, and which must be submitted manually. Sometimes we have to identify that there is a secondary plan, to avoid duplicate billing.

Some days I have to be a health insurance hunter, and other days I have to be a secondary claims health insurance hunter. Here are a few stories…

Why is there a payment and denial? The best insurance plans are the ones that automatically forward claims to the secondary plan – and let you know it upfront. We submitted a claim to Payer A1, and received a payment. Then we submitted a secondary claim to PayerA2, and received a payment – as well as a denial notice. Why? Because we sent a duplicate claim. That’s when we found out that Payer A1 automatically forwards claims to Payer A2.

The two copayments. We submitted a claim to Payer B1, and received a payment, along with a notice that the client had a copayment. The client paid the copayment. Then we received a payment from Payer B2. We didn’t know that the client had a secondary plan and we didn’t know that Payer B1 automatically forwarded claims to Payer B2. We refunded the client, with our apologies.

Why did they pay? We submitted a secondary claim to Payer C2, and received more than we expected. We immediately called Payer C2 to let them know about the overpayment, and set the check aside. Three months later, we received a letter saying that an “audit” uncovered the overpayment. Payer C2 demanded repayment – even though we never deposited the check – and threatened to deduct the amount from future payments, without apologizing for their mistake.

Why didn’t they pay? We submitted a claim to Payer D1, and received a payment, along with a notice that the client had a copayment. We submitted a secondary claim to Payer D2 for the copayment, but received a denial letter. Their explanation: the amount Payer D1 paid was more than the amount Payer D2 would have paid as the primary plan (even though Payer D2 is not the primary plan).

Are you satisfied with your health insurance plan(s)? Are your health care premiums affordable? What about your copayments or coinsurance?


Artwork courtesy of

Talking about teen anxiety and depression

May 8, 2018

I work for a nonprofit mental health counseling center, and I was happy to realize that the Hawaii Book and Music Festival expanded their program to include Wellness in Hawaii. Books and music strengthen our mind and spirit, and it seems natural to include to mental and physical health.

Because my son is entering the teen years, I was drawn to a panel discussion on “Anxiety, Depression, Teenage Suicide.” It was moderated by University of Hawaii professor Maya Soetoro-Ng, who began the discussion by revealing how teen suicide has touched her personally.

There were five panel participants: psychologist and director at Waimanalo Health Center Sid Hermosura; child and adolescent psychiatrist Sonia Patel; author, professor, and founding director of the Stress Reduction Clinic Jon Kabat-Zinn; psychologist Julie Takashima-Lacasa; and professor Thao Le, who called for a sense of joy and excitement even when talking about serious issues.

Maya began the discussion by asking, “In a time of great connectedness, why are we so lonely?” Aside from genetic reasons, family situations, and financial circumstances, there was a general consensus that screen time and social media contribute to a sense of loneliness and disconnectedness.

With screen time, “[teens] get caught in their heads,” Sonia said, and parents don’t want to upset kids by limiting it. Julie added that screen time is highly associated with depression, and teens who use over five hours of screen time are 71% more likely to be depressed.

We need to teach teens tools to manage social media, Sid urged, because “likes” and number of followers can become tied to self-esteem. Thao added that we can become addicted to immediate responses and “likes,” and social media makes it too easy to compare and judge ourselves against others.

What solutions are out there? asked Maya. We need to teach mindfulness in schools, Jon recommended, “we need to cultivate emotional intelligence.” Julie agreed, saying that we need to “cultivate self-awareness” and teach emotional regulation so that we can make better decisions. “Anxiety and depression are not individual problems, it’s a collective problem,” Thao stated. She advocated aina-based learning, where we can connect to nature and each other.

Sonia offered three everyday suggestions: sleep, meals with family, and less screen time. Sid suggested that primary care physicians and pediatricians can screen for anxiety and depression.

There wasn’t much time for questions from the audience, but a family court judge asked about ways we can address trauma in teens. Sonia said that in her practice, she helps teens identify trauma, separate trauma from their self, re-write the way they respond to danger to make better choices, and learn what triggers will trick your brain into making poor choices.

The panel discussion opened and closed with performances by singer/songwriter PraiseJesus Artis.

I wish we had more time to discuss the programs that are already in place to help teens, and perhaps even hear from young adults who experienced teen anxiety and depression.

On this day, to the sounds of music and the murmur of readers, the conversation was just beginning.

Communicating is critical to first aid

February 13, 2018

One afternoon, a client came into the office. He said he just wanted to rest. He sat in a chair, and then did a controlled slide to the floor. He stretched out on the carpet and fell asleep. I could see and hear that he was breathing easily, and he didn’t seem to be in any distress. I thought I might let him sleep, because I didn’t feel unsafe, but after a while I decided I needed help. The pastor at the church came to wake him up and escort him out of the office.

That experience stayed with me. I didn’t know what to do, and eventually I went to get help. But I wanted to know what I could do, as well as what it’s okay not to do. So I signed up for an American Red Cross CPR/AED/First Aid class.

The class was a combination of videos, discussion, and practical skills. We had an experienced instructor who gave us practical advice. The steps we are asked to take are simpler and less intimidating. Instead of worrying, How will I remember those steps? I found myself thinking, I could do that.

The most important thing I learned is communication.

ASK someone in distress if they need help. ASK if they are in pain, have allergies, or take medication. ASK if it’s okay for you to help them – get their consent – or, if it’s a child, ASK if a parent or guardian is present and get their consent.

Next, INFORM them about what you are doing. INFORM them that you are going to apply pressure to a cut or check their head for a wound. If they are choking, INFORM them that you are putting your arm around the front of their shoulder to support them as they lean over, so you can do back blows. It can be scary for someone who doesn’t realize that you are trying to help.

Then, TELL bystanders exactly what they can do to help. TELL them to call 911 and why –there’s a leg injury from a bicycle accident or a head injury or an unresponsive person. TELL them to find an AED (automated external defibrillator) — and if they can’t find one, to come back quickly. TELL them to look for an ambulance and escort them to the patient, or keep the crowd back.

I am so glad that I took the class, because just reading a first aid manual can be overwhelming. It may tell you what to do, but not how to act. Even if I never use the things I learned, I feel a little more confident about handling myself in an emergency.

You, me, all of us are often the first responders in a crisis. It’s up to us to evaluate a scene, offer aid or comfort, and call 911.

Have you ever taken a CPR/First Aid class? Have you ever helped someone or been helped in an emergency? How do you react in a crisis?

Health insurance hunter

February 6, 2018

I work for a small nonprofit organization in Hawaii, and it was eye-opening to enter the mysterious world of health insurance coding and billing. Every medical procedure is reduced to numbers: provider account numbers, tax IDs, subscriber account numbers, dates of birth, diagnosis codes that prove medical necessity, and billing codes.

Sometimes, the confusing, frustrating, and impersonal claims process makes me long for a single-payer health care system.

Some days I have to be a health insurance hunter. Here are a few stories…

Who’s the payer? We submitted a claim to Payer A, but they denied the claim. Payer A said that yes, the client has insurance, the client had a “replacement” plan, and Payer B is responsible. Payer B said that yes, they are the insurance provider, but they are the secondary payer. We need to bill Payer C, and then submit a claim to Payer B.

There’s a lesson here: because of privacy issues, health insurance companies can’t share information indiscriminately. When there is more than one health insurance plan, clients have the responsibility to contact their plan administrators.

Where’s the claim? We submitted a claim to Payer D. Months went by, and we didn’t receive either a reimbursement or a denial letter. Payer D told us that the claim was rejected because of an error, but no rejection letter was sent. If we hadn’t called, we would not have known about the denied claim. We were able to resubmit the claim, and were eventually paid.

 Where’s the payment? We submitted a claim to Payer E. Months went by, and we didn’t receive either a reimbursement check or a denial letter. Payer E told us that we were “out of network” and that they sent a check directly to the client months ago. We didn’t know it, but the client was supposed to pay for the service out-of-pocket and Payer E would send them a reimbursement check. This has only happened twice so far.

Where’s the authorization? We submitted a claim to Payer F, but they required an authorization for services. We submitted the authorization request, but Payer F told us it was the wrong form. We submitted the correct form, but Payer F told us the provider number was wrong. We submitted the corrected form, but Payer F told us that another, optional part of the form was incomplete. Lesson:

What’s the deductible? Payer G denied a claim, and we needed to find out why. The claim was submitted correctly and the procedure was covered under the plan. We learned that the client had an annual deductible that has to be met before Payer F paid any claims. With health insurance premiums rising, many people (myself included) are moving to less expensive plans with higher deductibles. These deductibles are quickly becoming a serious problem for people with chronic illnesses or conditions.

Despite the aggravation, at the end of the day, I don’t think a single-payer health care system would be an improvement. It might be simpler, but it would be more restrictive and less flexible, because clients and providers would have no choice and little power to fight against denials and reimbursements.

Are you satisfied with the way your health insurance company works with your doctors? Have you generally had easy or frustrating experiences with medical claims?


Artwork courtesy of

Full circle about single-payer health insurance

February 21, 2017

Choose Your Health Insurance

I never understood why there is so much support for a national, single-payer healthcare system – until I started working in a small medical office.

Just last year, I believed that commercial health insurance is good for consumers. It is better for us as patients, in terms of flexibility (choosing the plan that fits you), choice (access to doctors you trust), and price (insurance plans must compete for your business, keeping their premiums reasonable and benefits attractive). It is better for healthcare providers, because they can choose which healthcare plans to accept; insurance companies with unreasonable requirements or low reimbursement rates could be avoided. Theoretically.

For healthcare providers, our current healthcare system can be a nightmare. Each healthcare plan has different copays, different deductibles, and vastly different levels of reimbursements. Some payers reimburse providers promptly; some payers may take months. It’s not fair to providers, who may have to wait a long time before they get compensated for their work. How many of us would go to work if we are not sure how much we will get paid, or when we’ll get a paycheck?

Even a small medical office, with a limited number of healthcare providers and billing codes, generates a lot of paperwork. Electronic billing helps, but there are still pre-authorizations, progress notes, requests for documentation, paper claims for payers who don’t accept electronic billing, and customer service phone calls to find out the status of a claim or why a claim was denied.

I’ve had problems with two insurance companies who each insist that the other is “primary” and should be billed first. I’ve had claims that get lost in the system, and then have to be “escalated” for payment. I’ve learned that military plans are “secondary” payers – except when they are “primary” payers.

For healthcare providers, I see the allure of a single-payer system: one claim form, one customer relations contact, one billing contact. Theoretically.

But the more I learn, the more I realize that a single-payer health insurance could be an even bigger nightmare than our current system. A monopoly on healthcare coverage, authorizations, and payments would not be good for anyone.

Consumers would have a limited choice of plans and providers, and under current law would be forced to buy health insurance that they may not be able to afford. Healthcare providers would have little recourse if the single-payer refuses a claim or underpays a claim.

In a short time, I’ve realized that the government health insurance payers (military, veterans, Medicare, and Medicaid) are the most difficult payers to work with. Government payers often take longer to reimburse providers – sometimes three times as long as commercial insurance companies. Government payers often pay providers less – sometimes 25% less than commercial insurance companies. Government payers often fall short in informing people that they need to have an authorization before they see a healthcare provider – and there is little recourse for appeals.

I was beguiled by the idea of single-payer health insurance, until I realized that the single-payer would be a government payer. I’ve come full circle, skeptical that single-payer health insurance would be an improvement over our current healthcare system.

If you work in the healthcare profession, what has been your experience with medical billing and claims? If you’ve lived in a country with a single-payer health insurance, what has been your experience with medical costs and care?


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