On Loopholes, Jumping Through Hoops, and Silly Holidays.

In which Sheila returns to the use of footnotes in hopes of being perceived as somewhat funny. 

Ok, here’s the situation*: Vermont is a silly place. I say that with the utmost respect for the Green Mountain State. I’ve lived here most of my life, and, if you’re not from Vermont, it really is as amazing as Bernie Sanders said.**  One of the really amazing things Vermont does is declare “Town Meeting Day” a holiday so that everyone*** can go to their respective Town Meetings and vote on things like school budgets. Literally, every state office is closed on Town Meeting Day, and, to my knowledge, Vermont is the only place to engage in this strange custom. Now, don’t get me wrong, it’s a wonderful thing to encourage people to participate in local politics and in forming the budgets of the local schools and such, however (and it’s a big however) it is incredibly inconvenient should you find yourself in the situation in which I found myself this morning.

Quick little personal note – I am currently unemployed and, according to all the doctors I’ve spoken to, am to remain unemployed with the exception of “possibly being able to work a part time, low stress job which is conducive to a consistent schedule to successfully prevent any intensified PTSD or BPAD symptoms.” Saying that this is a massive pain in the ass is an understatement. There’s something else you may not know about me: I’m kind of a work-a-holic. If I had my way, I would consistently work a minimum of 50 hours a week. It keeps me busy . All this “down” time is driving me nuts.**** So, I’d like to be working, but the powers that be, it would seem, have a different idea. With not working comes the loss of the benefits I had while working, the most pressing one being health insurance. To be absolutely clear, no one knew that my health insurance had lapsed until Friday afternoon. I filled out the application online for state insurance on Saturday. So I have been as on top of this as possible. But it doesn’t happen overnight, and you really need health insurance if you are hoping to manage a chronic medical condition, especially one requiring expensive mood stabilizers.*****

Back to this morning: I realized yesterday that I had less than a day’s worth of one of my medications and no means with which to get more until the insurance stuff cleared. This stressful epiphany came as I was having a late afternoon meeting with a counselor at a local mental health organization. Like I said, the application is in, and I’ve been told, based on my application, I’m approved. But it’s not “official” until the paperwork goes through all the way. State offices close at 4 PM on weekdays, and I did not finish my appointment until 4:10 yesterday. Then, I couldn’t make the phone call to get that magic number that will allow me to fill my prescriptions today due to Town Meeting Day.

So, there I was, with less than enough of this medication I’ve been told I cannot go without to get through the day and apparently no recourse. I called my Primary Care office and explained the situation. They said they were not sure they could help, but “someone will get back to you.” I then called the local mental health organization. I got voicemail. The waiting game began as my anxiety steadily increased.

My PCP office called me back at around 2 PM. I calmly explained that I do not have insurance currently (but I will, and it will be retroactive to the end date of my prior insurance), that I was dangerously low on this medication that every keeps telling me I absolutely cannot stop taking, and I have no money to pay out-of-pocket for a partial RX refill. The lady on the other end of the phone seemed genuinely concerned and interested in helping me, and I could hear the attempt at a reassuring smile in her voice****** as she said that she could call my pharmacy, have them fill the prescription and bill the hospital for now, so my retroactive insurance could handle it when it kicks in.

Fantastic! Problem solved! That was surprisingly simple, I thought. ******* She said she’d call me back once it was cleared it with the pharmacy.

About 15 minutes later, my phone rings and it’s the same very helpful nurse. Her opening line, though, is far less helpful and reassuring than I anticipated. It certainly wasn’t “You’re all set! Just head to the pharmacy.”

“So, Sheila,” she opened with a tone of hesitation. Uh-oh. “Your dosage on this medication has substantially increased since the last time you saw your primary care physician.”

“Um… yeah. Last time I saw him I was fresh out of Dartmouth and not diagnosed Bipolar, so it was being used in a very low dose to manage anxiety. Now it’s being used for mood stabilization.”

“Ok, well, your primary doctor isn’t really comfortable writing prescriptions of psychiatric meds in such high doses. Do you have an appointment with a psychiatrist lined up?”

“Yes, but we’re not sure exactly how far out that appointment will be. I am working with [mental health agency], though, and will have access to psychiatric services through them. The idea with discharge from the IOP, though, was that my PCP could write the prescriptions in the interim. They were supposed to communicate with you guys about that.”

“Well, they haven’t, and your doctor is not comfortable writing scripts at these dosages. So you’ll need to talk with the people at [mental health organization] to set something else up. Also, with your recent hospitalization, I need to clarify that you haven’t had any thoughts of suicide. That’s another reason your doctor is hesitant to write such large dose ‘scripts. We don’t want you trying to overdose on them.”

And there’s the real problem. “I haven’t, and I won’t. These meds are the things that are preventing both manic and depressive episodes. If I stop taking them, then I might be in trouble. But I don’t see how getting the prescriptions I’ve been taking for the last month and half to get stabilized is considered more dangerous than stopping them and risking being unstable just because a doctor is nervous I’ll suddenly try to kill myself with the meds that are literally preventing me from hitting that point.”

“Well, it’s an issue of liability.” Ah, yes. Liability. In our litigation filled society, it’s a legitimate concern for medical professionals. But I briefly wonder what the lawsuit would look like if I was forced to stop taking this medication and then ended up hospitalized again or worse. 

“Ok, so what am I supposed to do?” My anxiety and irritation are pushing code red levels at this point. 

“Well, he’s willing to write a prescription for one day’s worth. That will get you through until tomorrow when you can call about your insurance and also connect with your interim counselor to establish interim psychiatric care until you’re established with consistent care.”******** She tells me to come pick up the one day’s worth of this currently essential medication, which she gives me at no cost due to this loophole she’s found.

This fiasco took me just about all day. It was stressful. It prevented me from doing several other things I was hoping to accomplish today, and I spent a good chunk of the day honestly concerned I would not be getting this medication and missing it for a day would send me into a tailspin and land me back in the hospital, because it’s been drilled into my head over and over again how essential it is that I maintain consistency with my medications.

Maybe it’s my inner cynic, but I can’t help but wonder if the reaction to this situation would have been different were this medicine for a “physical” health problem verses a “mental” health problem. I suspect the answer to that question is a resounding “Yes”. Fear and stigma, it would seem, extend even into the medical world. Which is pretty silly when you think about it. BPAD and PTSD are medical conditions. The chemicals in and physical structure of my brain are messed up. Medication and therapy are essential to correct those issues and maintain “normal” functionality, much like a person with diabetes needs insulin to stay healthy. But “mental” health is still viewed as being very separate from physical health, and mental health patients without an established psychiatrist tend to fall through the cracks of misunderstanding and legal concerns.

So, I’m moving into tomorrow completely unsure of how much of this can be resolved in the next 24 hours. I’m worried that my Primary will flat out refuse to fill the prescriptions I’m now acclimated to and dependent upon; I’m worried I won’t be able to get in with the psychiatrist for over a month (psychiatric appointments in Vermont are very hard to come by, it seems). I’m stuck in this system that simultaneously fears destabilized mental health patients and hesitates to write prescriptions for mental health medications to keep people stabilized.

I was discharged from IOP with no insurance, no way to refill prescriptions, and no established, on going psychiatry appointments. Yes, I’ve learned the skills I needed from that program, and mentally, I was stabilized and prepared to move on. But, when you think about going from two months of wrap around services to seeing a temporary mobile crisis counselor because they don’t require insurance or payments upfront (another loophole I’m currently utilizing) and having a primary care doctor completely unaware of your medication changes and, it seems, unwilling to maintain those changes short term, you can start to see how fucked up this system of ours really is.

I’d be lying if I said I’m not more than a little frustrated. “One day at a time” is fantastic advice, but I’m not sure it’s comfortably applied to prescriptions. I certainly don’t want to be moving through the next however-long-it-takes-to-get-insurance-and-a-psychiatrist one dose or one day at a time.

One thing is for sure, I will feel so much better once my on-going maintenance care is established and I have insurance. I’ll feel better once I can work again, and I don’t just mean working at a “low stress, consistent part time job,” I mean working. Full time, with benefits, in some capacity that feels meaningful. Because I’m not built for a “job”, I’m built for making an impact. I don’t mean that in a “savior complex” kind of way, I just mean that I am someone who needs to feel like somehow, someway, I am making a positive impact in the world.

But for now, I’m literally being forced to live moment to moment. And maybe this is where that DBT idea of Radical Acceptance comes into play. But make no mistake, tomorrow morning this girl’s coming out the gate (politely) swinging, with self advocacy and assertive communication skills cranked all the way up to 11.

*my parents are NOT away on a week’s vacation – an obscure reference, perhaps. OLD Will Smith – like before the acting gigs old.

** Unless you live in the NEK (I grew up in St. J and Danville, I’m allowed to say that.)

*** State and Bank employees

**** Too soon?

*****Seriously, these things are, like, $5 a pill and I am supposed to take 18 of them a day.

******Medical professionals have a “special” voice for mental health patients, I’ve discovered. Quiet and gentle, intentional, like verbally attempting to defuse a bomb, all the while sweating bullets and terrified of an accidental detonation.

*******Famous last words. Right up there with “Hold my beer.”

******** I think I’ve mentioned more than once on this blog how very much I dislike “interim” and “short term” care.

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