Health - Trigger Finger Costs

Oct 24^th 2017

We went yesterday for my pre-surgery dr appt for my right ring finger.  It has been two years since I saw Dr Araujo here in Trinidad.  He suggested we try one more cortisone injection but left it up to me to decide.  While I doubt that is going to do it, I had to try once more, so that is what I got yesterday.  In the past, it works for a bit and then the trigger finger comes back.  I have a follow up in a month.

Now for the interesting details of the visit that make it so different from the USA and probably the reason the pricing is reasonable down here in the Caribbean.

• First, we met in the doctor's actual office, not an exam room.  It is so much nicer.  He has an exam room off his office so we went in there for the actual exam but then back into his office for the wrap up.  Nice.
• Second - other than checking in at the front desk, the actual Dr is the one we saw next, not a PA, RN, or other, but the actual Dr.  He was the one asking what was going on.  
• Third - He did an ultrsound on each hand.  He did it himself, not someone else.  *I have trigger fingers in each hand - at this point ring and middle on each hand but only the right ring is really bad. 
• Forth -He did the injection himself.  An office staff brought in the dose and supplies but he did it.  This involved freezing the area, numbing with a local and then waiting for that to kick in (5mins - in which he typed on his computer notes to my file and yet continued to chat with us) and then did the actual injection.

Trigger thumb - left not working like the right

In the USA I would first see a med staff of some sort who would gather information.  Then a PA or RN to do a brief exam and diagnosis and then the Dr to give the final diagnostic.  Any ultrasound would have been in radiology and if in a hospital, read by a radiologist and then sent to the Dr.  In a clinic it would have been done in radiology dept and then sent to Dr for reading.  My injections in the USA have always been given by the PA, never the Dr.  

Billing in Trinidad - Dr fee (by the way, Dr Araujo is a board certf. Orthopedic doctor with training/schooling in Trinidad, UK and US) $600TT -approx  $100US.  Ultrasound was listed as one for $400TT - approx$66US.  The injection was not even listed. 

Trigger thumb fixed in USA several years ago

Billing in the USA - first of all, good luck even pricing healthcare costs of any sort before or during.  It is really hard, seriously.  I have not done an in depth lately but a cursory look online yesterday said the cortisone injection alone would be anywhere from $116 to $343 in our zip code.  One search said a hand exam would be approx $1000+ but that is very rough estimate as there were no details and unknown if this was with a specialist (ortho dr).  I could not find what a hand ultrasound would cost.  I have no doubt it would be billed as two ultrasounds in the USA -right and left hand.  

When I priced the actual hand surgery in 2014 I was able to make several calls to billing depts in KC to get specifics.  I felt like I was close to actual costs as I had the CPT codes.  Trigger finger surgery in the USA in 2014 in KC would have been approx $10,000 US with no insurance.  Negotiated insurance rate is usually one third to one forth the uninsured price, so $3000 to $4000.  Of course this is only after deductable is met.  Our current insurance has a high deductable of $5,000 each.  Anything over routine annual test hits against the deductable first including ultrasounds, xrays, injections, surgeries , etc.... Those would be billed at the negotiated rate but still paid in full by us up to the deductable.  Then of course once the deductable is hit, some is fully reimbursed and other healthcare costs are a 60%-40% or 80%-20% reimbursement depending on procedure & plan. Trigger finger surgey in Trinidad in 2014 would have been $800 US plus some change for pain meds (cheap here) and follow up Dr visit so...$900'ish.  

And we wonder why our healthcare costs are so out of control in the USA.  Of course, I have had to do a bunch of research and digging to even get all of this.  Luckily, I had a job in the past where I could makes numerous phone calls, leave messages, wait on hold and take return calls to find out pricing and of course follow up in incorrect billing (more often that not by the way)  What of those that work a on a production line or in a mine or other where they don't have flexibility to makes calls during working hours?  

It is no wonder that our European friends shake their heads when it comes to US healthcare.  Many are afraid to cruise to the US for fear that something might happen physically and they will need emergency treatment and can't afford it.  Example - UK friends had another UK friend who broke his finger while cruising the east coast.  Simple finger fracture.  I don't know if he did a hospital or clinic but xrays were taken, he saw a doctor,  got a finger splint and then a bill for $5,000.  He nearly fainted.  Our friends said in UK the exact same would be $150 pounds. 

Health Onboard

Oct 13th 2017

I have been meaning to blog about health items aboard sv Honey Ryder for quite some time.  Interesting that I picked today since I'm feeling a tad under the weather.  Nothing serious, just a sore throat indicating that a cold is in my future.  No doubt some airplane bug I picked up with all the cruisers flying back in here.  So many cruisers with grandkids slobbering all over them right before they board the airplane to come back here.  Ugh – kid kooties!  I am trying to rest and stave off the coming cold - yeah right!  But "resting" does give me the chance to blog a bit.  Some of this might be a bit too much info (TMI) but maybe it will help others in some way. 

Anyway, health items – I am going to discuss in categories.  We actually stay pretty healthy on sv Honey Ryder.  An occasional rash, cold, sore or pulled muscle.

 

Skin Rashes -.  Our most frequent challenge onboard is skin rashes.  In this hot, humid, sweaty environment, we end up with our fair share of skin rashes.  Some simply come from the environment – (wet, sticky), while others are contact rashes (contact dermatitis) from various plants and fruits (let's not forget the Mango Rash).  Still other rashes come from the sea - our being wet with seawater on a daily basis as well as stings and scrapes from microscopic sea creatures.  A recent inventory of our med kits proved that rashes are our biggest challenge.  We have a VAST assortment of meds to treat all kinds of skin rashes, from simply over the counter to strong creams, and pills - Prednisone to Cipro.  On the serious side, Tom did end up with a case of Cellulitis.  His was relatively minor.  We only knew what it was because a fellow cruiser got a bad case in Guyana / Tobago five months earlier. His took three rounds of different antibiotics to kill it.  Scary!  Because we caught Tom’s early and it was not as serious, I started him on a basic, old school antibiotic, thinking that if that one didn’t work, we have two stronger, different antibiotics we could work our way through if needed.   As for me, I have a recurring neck rash at the base of my neck.  It has been diagnosed and I have prescription body wash to keep it at bay and cream (which works only so so) if I do get it.  This season I decided to try something new, Anti-itch Monkey Butt Powder.  I know, crazy name.  Tom used this for the first time this summer while doing a crazy 340 mile endurance canoe race.  They used it on their hands to keep from blistering.  It was amazing and worked really well as he only got 1 little blister after 58 hrs of constant paddling.  So, I decided to bring some back to try on my neck.  I have never been a powder person at all so this was a first.  I powder my neck each night before bed.  It has worked wonders in keeping sweating down and thus I have yet to get my neck rash.

Muscle Relaxer -  We have a supply or two of generic Flexrall for pulled muscles and strains. 

Pain Killers – We have an assortment of pain killers.  Over the counter equivalents of ibuprofen and Tylenol – Panadol  * Panacetamol (brand you find this in Caribbean, UK and Europe and probably the rest of the world).   Nubtone is generic Relafen.  I have 500mg and 750mg.  Finally, strong pain killers like Vicodine, Oxycontone and such. 

Filling Prescriptions  – Many prescriptions can be filled in the Caribbean without a new script.  In fact, most of the time, that is the case unless it is a really serious “controlled substance” type med.  If you have a bottle of blood pressure med or cholesterol med or such, you simply take the bottle into a pharmacy and they fill it.  And this is at all pharmacies big and small in all Caribbean countries.  So lest you think it is just some shady, local pharmacy.  No.  Sometimes they don’t have the exact USA brand.  We often end up with South American or European or India brands.  And I know many USA persons worry about counterfeit drugs.  However, again, these are legitimate pharmacies just like CVS or a smaller regional like Bruce Smith in KC.  The label often says “Bayer South American” or some other big pharma company found in the UK or India.  If you think all your prescriptions you get in the US are “Made in the USA” think again!  They may be US based but those pills are coming from someplace offshore in most cases.  Sometimes getting the other brand will mean two pills to make up for the one pill dose you might get in the US.  Additionally, many, many items that are prescription only in the USA are available from the pharmacy without a script or bottle at all.  For example, birth control pills are available without a script.  When we're stateside each year, we try to do our routine, annual doctor appointments and tests but only if they are covered 100% by insurance.  Otherwise we go here in Trinidad.  We work with the US doctor/nurse/PA to be sure that they are prescribing generic drugs off the discount pricing list at Wal-Mart Pharmacy as much as possible.  I am talking about the $4 and $9 drug lists.  We actually take that list to our appointment.  This takes some work.  Healthcare providers are not yet used to patients managing the scripts and costs to this level.  We have had to be firm at times.  Of course, not everything is available on the discount list.  For those items not available, I hit the internet for discount coupons.  This takes some work at well.  I find GoodRX the best – no sign up or login.  It is amazing how much the coupons help – big discounts.  Wal-Mart seems to have the lowest discount list costs and regular costs.  I also find they are the best at applying the coupons and working with me to suggest additional cost savings.  I try to go early in the morning before it gets busy.   When we get our scripts filled at Wal-mart I do not use insurance.  Our insurance does not cover prescriptions.  I have no idea of there is a discounted rate.  I don’t think there is or if there is, it is not much.  By using drugs from the $4 and $9 list and no insurance, we can purchase a year supply,  Using insurance, you are only allowed 30 -60-90 day supply depending on the med.  Not good for daily med as a cruisers out of the country.  Frankly I have never understood this.  If I am on daily med, prescribed by my doctor, why the hell can’t I go ahead and get a year supply?  Anyway, back to our annual supply – any specific drugs that are not daily like antibiotics or pain meds, we try to get as many refills as the healthcare provider will allow.  Wal-Mart is great because they don’t even make me come back for the refills.  They will let me get all the refills.  I just tell them I am going to be traveling outside the USA extensively and I want to have meds with me in case.  I let my primary know in advance of moving aboard that we were going cruising and what all that entails –well in advance.  Right before moving aboard, I had a full range of tests and he prescribed a wide variety of drugs for us to use just in case. Tom’s doctor did the same.  It has been a little more of a challenge since.  For example, last year I wanted a new prescription for Prednisone.  I called the doctor’s office.  They wanted an appointment.  When I called back, I explained “I don't have a rash now.  I will be traveling internationally in the Caribbean over the next several months and I want have this with me.”  They still wanted me to come in.  “WHY?  I don’t have the rash now?”  Didn’t matter, I had to come in which mean an office visit fee.  No thank you.

Records - Speaking of which, be careful what you tell USA healthcare providers because it goes in your record.  In other words, we now say “We will be traveling extensively out of the country for several months” which is true.  Some insurance limits how long you can be out of the country and still have coverage in the US.  BTW – our ACA (BCBS KC) only covers us in the USA.  We also have DAN (Divers Alert Network) insurance that covers us while cruising but really only for emergencies and such.  Back to the whole be careful what you say, I was shocked at what my medical records said when I gathered them all prior to setting off.  It was the wording.  Example – you go to the doctor and you always have to fill out a basic health form – Do you have this?  This?  This?  When?  Family history of this?  This?  Have you ever smoked?  Drank?  How much?  Ect….right?  What shows up on your record is not yes or no with the details you put but “Patient CLAIMS this.  Patient CLAIMS that.”  OMG!  I know that sounds like a small change but think about how big the ramifications of that small change are.  There are other little things.  So be truthful but be careful, don’t over share unless you are really comfortable with your doctor/provider.  You should get a copy of all medical records.  Start early, this is a process and involves fees to third parties.  Electronic are the best.  Backup on a drive or Dropbox is good too.  I have also made a several quick spreadsheets that I have printed off and keep in a folder.  When we go to a doctor now, we take the spreadsheets.  Tabs are as follows :  Sabrina Drs, Sabrina Med, Procedures – starting with most recent back to when we moved aboard with additional for past surgeries, important procedures and inoculations, Sabrina Drug Allergies, Tom Drs, Tom Meds.  Yes, he is much healthier than me, his lists are shorter.  I update the lists as we travel and print out new spreadsheet each hurricane season.  Having the printed form is just easier for us then having it on a phone, ipad, flashdrive or other.  What if your cell phone/ ipad is loss/damaged/stolen or battery goes dead or not access to the internet and thus Dropbox on the way to the doctor/clinic, hospital? 

Health Insurance –

Affordable Health Care was a huge relief for us when it passed.  We both have preexisting conditions.  Mine was an exception that WAS NOT covered prior to ACA even though I had surgery to correct and am doing fine.  Under ACA, we choose a plan each year that is a basic level with high deductible ($5000) each.  This covers us when we are in USA in case of emergency or serious illness.  DAN (Divers Alert Network) insurance is $155.00 each.  It covers emergency, serious illness and evacuation if needed and approved.  This is not limited to diving but covers us while cruising.  When we need simple treatment in the Caribbean, we pay out of pocket.  Healthcare costs are much, much, much lower here.  In fact they are actually reasonable.  I will be doing another blog specifically on this.  The ACA insurance is based on our income which is substantially lower now that we are not working.  Thus we qualify for subsidies.  Our insurance was approx. $200 a month for both of us last year and $150 a month for both this year.  It went down!  On the same income it went down!  Again, ours is a bare bone basic plan with high deductible.  We also live in a metro area so we had options on plans and found most healthcare providers take it.  However, with the all out war on ACA, who knows what will happen next year. 

Warning Political Rant Ahead  – ACA is not perfect.  No Government plan is!  It needs tweaking and fixing NOT replacing.  It works!  Shame, shame, shame on politicians if they repeal and leave millions of now insured American’s without equal insurance or no insurance.  There will be hell to pay if that happens.  Serious, hell to pay!  DO NOT leave me a comment that health care is not a right.  Are you freaking kidding me?  Healthcare and care of ALL American’s is the morally right thing to do.  In a civil, well functioning, modern society you should not have to mandate healthcare for all but want and demand it for all.  A healthy society is a functioning, good society.  And don’t tell me people should earn it – really?  The majority of all Medicaid (poorest of the poor) are children – CHILDREN.  So implementing a mandatory work requirement is just stupid.  Ohhhh……don’t get me started.  But I know I am probably preaching to the choir here so I will stop.  Rant over, back to health aboard sv Honey Ryder.

Coming up next - healthcare costs

         

Anit-Malaria Meds and Side Effects

I know what some of you might be thinking about my previous post on Shots Needed for Travel and specifically Anti- malaria meds.  My cruising friend Sarah said "Be sure to check the WHO (World Health Organization) web site.  Anti-Malaria drugs can have some quite nasty side effects."  I had heard this before.  But what exactly does that mean?  A few nights ago several of us cruisers were talking about anit-malaria drugs.  It seems some malaria drugs can cause weird dreams and hallucinations.  Really?  I am currently reading a Margret Atwood book, weird dreams are a nightly thing.  Same is true when we binge watch Breaking Bad, Son's of Anarchy, Game of Thrones or even Madmen for that matter.  And hallucinations?  Ha - I went to college at K-State!  An 11:30AM Saturday football game with full tailgate will bring on some interesting hallucinations of fuzzy purple penguins for the late night trip home.  The 12:00 - 4:00 am watch on passage can bring about some really crazy hallucinations as well.  After seeing a military drone earlier in the day, I was convinced it was back and taking pictures of me in the cockpit during my overnight watch on the last passage into Trinidad.  It turned out to be lighting......I guess......lightning that flashed on a regular basis just like a camera flash.....hum?

Anyway, the directions from the doc on the anit-malaria meds are to start one week before we arrive to our destination and continue through our visit and then four weeks after we depart.  This should give us plenty of time to become fully aware and accustomed to any side effects.  One comfort is that the doc writing the malaria scrip is himself on the very same anti-malaria med having just returned five days prior from a bird watching expedition in Peru.  "I take the very same anti-malaria meds I am prescribing." 

All joking aside, we know there are side effects and we will be careful.  As Princess of the Mozzie bites, I don't really have a choice.  I MUST take anti-malaria.

Shots Needed for Travel

Look out world - have immunization logbook, will travel

NO - I am not talking about Jello shots.....although it is K-State football tailgate season.  Go Cats!  I am talking about immunizations.  Traveling around this big blue planet there many areas that require immunizations to help keep us healthy.  We want to stay healthy.  We are not anti-vaccination freaks out to infect others and spread.....oh never mind.  We got our Hep A and B as well as a tetanus booster when we traveling to The Bay Islands of Honduras in 2009.  For this season's "Don't Drink The Kool-Aid Trip"  d-oh.....I said I wasn't going to call it that......anyway.....for our Guyana trip, we needed to get Yellow fever and Typhoid shots as well as a scrip for Malaria meds.  Actually, it turns out that we probably should have had our Yellow fever shot for the southern Caribbean.  Side note -   When I originally booked our airfare from Trinidad to the USA back this spring, it made no special notice of Yellow fever.  However, when I went to triple check our reservation three days before our flight out, a popup appeared saying something to the effect of "You are traveling from a known Yellow fever region.  You may be required to show proof of your Yellow fever vaccination when entering the USA."  Rut-ro.  No time to get it now.  Fingers crossed, we were not asked when we landed in Ft Lauderdale.

Once we were back in KC this summer I did some inquiring about Yellow fever and specifically the yellow colored international immunization logbook.  However, I knew we would wait and get the shots back here in Trinidad.  1.)  Price - much cheaper in Trini.  More below on this  2.)  Healthcare professionals here in Trini are much more knowledgeable on Yellow fever here than in KC.  D-uh, of course they would be!  I don't believe there are many cases of Yellow fever in KC.

Last week we went to get our shots.  There are many places to go which include a local medical clinic but I wanted to be sure we could also get the official international logbook as well at the same time.  Running around getting shots and then going someplace else for the logbook and then back for it to be officially filled out all via Maxi Taxi's and walking in the heat of the day did not sound like a scavenger hunt we would be interested in.  Dr Stuart Millar was a one stop shop.  I booked the next appointment opening for two days later.

On Thursday, we took a Maxi Taxi into POS and walked several blocks to his office.  We arrived early just in case traffic was a mess and sweaty from the walk.  We didn't mind waiting as the office was nicely air conditioned and we were able to get in early.  This was despite the fact that the waiting room was fairly full.  It seemed nearly 1/2 of the people waiting were also there for Yellow fever shots, many had on official work clothes for the oil industry and this was the Yellow fever shot production line.  Dr Stuart was friendly but got right down to business.  Stick, stick, stick, stick....."now come in my office."  We chatted while he filled out our official international immunization logbooks and wrote out the malaria med scrip.

I was also fighting a lingering cough from something I picked up back in the USA.  He gave my lungs a quick listen and prescribed an antibiotic.  However at the end of our office visit he said "Oh wait a minute.  I think I have a box of antibiotics I can just give you."  He looked in one of the cabinets and came out with not just a sample but a full treatment dose.  "Here.  Give me the script back and just take these.  That will save you a few dollars."  

We were out the door before our schedule appointment time.  Nice!

Cost breakdown -

• Johnson County Health Dept wanted $160 for the Yellow Fever shot.  *I didn't ask about Typhoid or Malaria pills.
• Trinidad Yellow Fever shot $400 TT each or $66 US each.
• Trinidad Typhoid shot $350 TT each or $58 US each.
• Dr visit for cough $250 TT or $41 US.
• FREE box of Augmentin (14 tablets)
• Trinidad total $1750 TT or $291 US
• Malaria med - Lariam 3 boxes $628.32 TT total or $95.00 US.  *Dr said "Whose name do you want the malaria scrip in?"  I asked "Don't we each need one?"  "Not necessary as you will just share.  I will make it out in your name."   Okay.  

Mr Pink

"Why do I have to be Mr Pink? I don't want to be Mr Pink.".   Steve Buscemi -Movie Reservoir Dogs

Cap10 Tom arrive to s/v Honey Ryder with a major case of poison oak. Sunday night he dashed over to one of the rentals to pick up some fallen branches and pulled some "weeds, vines and such" for good measure as he left. This rental has had a notorious rep for poison oak in the past but we had it professionally removed (we thought) a couple of years ago. It wasn't until yesterday that the rash started popping out. Today it's a case of full blow poison oak.

Usually our first stop on the way to the boat is for food and liquor (not necessarily in that order). Today stop #1 was for calamine. Yep, as I type Mr Pink is napping next to me. Poor guy. I feel for him. I got a wicked case many years ago at the same rental. Details are too gnarly but it took two doses of strong steroids and a month to get mine to abate. Oozy but very productive month. Eeeew.
UPDATE - a visit to urgent care this morning got Cap10 Tom some oral steroids and a shot to jump start the healing.  
*FYI - once you have poison ivy, oak or sumac (WTF does it even look like) you are more susceptible to it.  Some literature says differently but our experience is that we are more sensitive to it as time goes by.

**Mangoes are in the same family as the above. The oil of the mango skin and tree can cause a similar, smaller rash (Mango Rash).  The link on Mango Rash is to Lance Armstrong's Live Strong.  I am not sure why a testicular cancer surviving bike rider has info on mango rash's on his foundation web site -( insert numerous jokes here) but he does.  If you are like me and mango is your favorite fruit then you might cut it open like I do... carve out the yummy flesh and then turn the remaining skin inside out and naw every last bit of juicy goodness out of it. If you do, beware that the oil from the mango skin mixes with the noshing goodness and a few days later you might break out around your mouth with a tiny rash similar to poison ivy. If you forget to wash your hands really good and instead just wipe them off after cutting up a bunch of mangoes and then put sunscreen on your face, ears, neck and chest......that same rash will appear a few days later and itch like crazy. YES, it will.

Now ask me if I have changed the way I cut up mangoes? Hell No! I can't possibly leave that extra juicy goodness for the garbage bin. I still chew every last bit of yumminess out of the flesh. I am just extra careful to wash my face, hands, forearms and such with soap after.

***Apparently this whole plant family is or can be poisonous in some form or fashion to some people.  But remember....while we have previously stayed at a Holiday Inn Express, we are not doctors or medical professionals of any sort.  Do your own damn research on the topic!
So for now Cap10 Tom is a chillin (and oozing) and isn't that what boat time is really about anyway!  The chillin part that is, not the oozing part so much.