Suzy’s Story


We are infinitely more than our limitations or our afflictions

– Jeffrey R Holland

We interviewed several occupational therapists recently and three asked: Can you tell me the story of Creative. Why did you start it?

One of the reasons was the Kiles.

I first met and become friends with the Kiles over 30 years ago when I lived in Edgewood, Pennsylvania, a near suburb of Pittsburgh. The Kiles had two daughters, Sally and Suzy, who were about the same age as my youngest daughter, Dawn, and they all played together.

Suzy was a child with Down Syndrome. One day Suzy’s mother Ellen told me what had happened when Suzy was first diagnosed.

The doctor was a well known expert in his field practicing at the prestigious University of Pittsburgh Medical Center.

That doctor told the Kiles that Suzy “wasn’t going to make it.”

Ellen looked right at him and said: “Suzy is my daughter and she will make it. I will make sure of that.”

Not only did she make it under Ellen’s care, but Suzy flourished.

I was fortunate enough to get to know Suzy. I used to take my children on excursions to museums and other places of interest. One weekend Dawn asked if we could take Sally and Suzy. I said it should be okay but I’d have to check with Ellen.

I went to the Kiles’ house and asked Ellen:

“I’d like to take the girls to the Carnegie Museum. I know that Suzy has a shunt. Is it okay that I take her? Is there anything I need to look out for?”

I’ll never forget Ellen looking at me, staring silently for a long time. I thought I might have said something inappropriate, crossed a boundary that I wasn’t aware of. Finally, she said:

“I’m sorry. I was never asked that question and never thought about it. No one has ever asked to take Suzy anywhere.

“It will be fine. If something happens all you or me or anyone can do is call 911. And it’s very unlikely.”

Time to time through the years Sally and Suzy and Dawn and me had fun excursions. Suzy was thriving, loving, and curious, a joy to be with. Eventually I moved away and lost touch with the Kiles, but they will always be in my heart, inspiring me. I often think of Ellen’s response to the doctor and the excursions with Dawn and Sally and Suzy, the sweet girl no one thought to take anywhere.

The Kiles are my heroes and one of the reasons I co-founded Creative. Here we affirm the unlimited potential in each of us.

By the way, we hired one of those therapists, a wonderful OT named Liz Souza (no relationship to and spelled differently than John Philip). She’ll start at the end of the month.

(The names of the family were changed for their privacy. The story is true.)

My next article on this theme will address the dangers of pejorative terminology.

Richard Feingold, Co-founder

Modified Music – a High Level Perspective Part 1

Your brain has a natural ability to physically change itself by creating new pathways and connections in response to your experiences. This neuroplasticity can be positively stimulated by engaging in the right activities, often enough, over a sufficient period of time, resulting in positive life changes. Modified music through neuroplasticity creates measurable changes in the brain. (Adapted from the Advanced Brain Technologies website)

[Disclaimer and disclosure: I’m not a therapist nor have any kind of medical degree. Furthermore my story is anecdotal. And personal. One key personal element is that I have suffered anxiety and depression on and off all my life.]

Over the last several decades scientists, doctors, and therapists have developed new transformational treatments for children with special needs. Judicious and inspired use of recently discovered habilitative methodologies have improved many lives. In this essay I discuss one modality in particular: modified music.  

Regarding the latter, when Judy (my wife and our Chief Therapist) first introduced the idea that modified music could have a profound positive clinical effect I was…skeptical. Yet, the more I researched and dug into it, the more I understood and appreciated how and why it worked.
Several months ago at Judy’s urging that I begin a modified music program. I have been improving ever since. Modified music has helped and continues to help with my stress, anxiety, and depression. It has been and continues to be the most effective therapy that I personally have had. In addition, I’ve seen its successes in the children and the occasional adult that we treat.
Understanding how and why modified music is an effective treatment has been an interesting journey for me. Somewhere in the midst of that journey it struck me  that music is a profound and essential element of human communication.
Music has been part of human civilization for eons. It has been referred to as the universal language and is found in every society known to anthropology. – Arlene R. Taylor PhD, “Universality of Music
Watching a movie with the music muted would underscore its importance in communicating context as well as emotion.

Our journey of discovery begins with the genius of Alfred Tomatis and the serendipitous confluence of his medical and musical capabilities. Dr Tomatis, a French otolaryngologist from a family of musicians, several decades ago discovered and refined the relationship between listening to (ultimately modified) music and treating disorders such as reading problems, dyslexia, depression, severe schizophrenia, and autism.

As a scientist he discovered casual relationships between our sound processing and brain development. And that the process, amazingly, begins early in pregnancy.
In Part 2 we continue this discussion expanding on the the discovery and understanding of modified music.
There are 4 leading well established scientifically based modified music programs, each of which we are certified in: The Tomatis Method, Therapeutic Listening (TL), integrated Listening systems (iLs), and Advanced Brain Technologies (ABT) The Listening Program (TLP).
We work with families interested in modified music therapy to find the best fit. The latter has many considerations such as availability, logistics, clinical relevance, and budget.
  
Regarding the latter, these programs are rarely covered by insurance. Thus we’re always looking to improve affordability. That’s why we are particularly excited about the latest offerings from ABT including rent to own, streaming, individual and family plans. All have greatly improved the affordability of their offerings.
  
Whether you’re a current or previous client or new to our practice we’re happy to provide a free consultation with Judy to see if any of the programs are a good fit, and if so how to most affordably provide them. Talk to your therapist or call 703-910-5006 or email info@creativehealthllc.com.
  
Richard Feingold, Co-founder
 

Health Insurance: Maximizing Benefits (Part 2) – Concepts and Terminology

Part 1 introduced health insurance and focused on history and overarching philosophy. We will now review the types of insurance and what it means to be in or out of network. We begin with concepts and terminology.

When I studied rhetoric, I learned that mystification referred to the use of special terminology to convince lay people that specialists are more knowledgeable. I found it ironic that the use of the term “mystification” by rhetoricians was an instance of mystification. Nonetheless I find a fair amount of mystification in health insurance terminology.

Let’s begin with the concept of insurance itself. Typically, insurance pays or reimburses for relatively infrequent and occasionally catastrophic negative outcomes that result in loss—auto accidents, fires, storm damage, etc. In contrast, health insurance pays or reimburses for frequent and expected services as well as the less frequent. I’m stating the obvious to point out that healthcare decisions are being made by mostly for profit organizations whose structure and culture is to compensate for loss.

Indemnification is used in the health insurance context to describe insurance policies that protect you from loss due to health related expenses by pre-payment or reimbursement.

In contrast are health maintenance organizations (HMOs). Initially and historically, HMOs maintained your health by providing all necessary medical services. Today, HMOs offer limited or no choice in providers for lower costs.

In a pure indemnification model, you would choose any provider at any time and the insurance would pay or reimburse you. Period. In a pure HMO, your choice—at best—would be limited to providers within the HMO. Furthermore, the HMO would determine whether or not you needed services.

Pure indemnification is rare in private policies. (Interestingly and perhaps tellingly, Medicare is pretty close to pure indemnification. So is Tricare Standard, a policy for active military.) Most non HMO policies have various degrees of choice. In general you pay more for being able to choose.

Let’s look at some key definitions.

In network (sometimes participating). This refers to a provider who has a contact with the insurer and has agreed to accept the contact (allowed) fee as full payment for the various services. If the provider bills for an amount higher than the agreed fee, the fee is adjusted. This adjustment is sometimes called an insurance write-off.

Out of network (sometimes non-participating). This refers to a provider who does not have a contact with the insurer and is free to charge whatever fee they find suitable and appropriate. If the provider’s fee is higher than the allowed fee, the provider may bill for the difference between the allowed fee and their fee. This is known as balance billing.

Now let’s look at insurance plan designations.

In additional to HMO, one of the most common is Preferred Provider Organization (PPO). These allow you to choose either an in network provider or an out of network provider, with greater cost to use the latter. The Point of Service (POS) plan is a variant of the PPO. The difference is that you are required to get a referral to see a specialist.

A variant of the HMO is the Exclusive Provider Organization (EPO) which allows you to choose within the network. While its name sounds similar to a PPO it is a form of HMO.

The requirement for referrals and other types of authorization is called gatekeeper functions.

There are terms referring to payment.

The first is deductible. This refers to the amount the client is responsible for before the insurance will begin to pay. Deductibles may apply globally or they may apply to categories of services. For example, there may not be a deductible for office visits, but there may be one for tests. Deductibles typically only count the insurance share of a reimbursement, making it take longer than expected to be reached. Until a deductible is met, the client is responsible for the full fee.

There are two other ways a client shares the cost of a service. A copay is a fixed amount for a particular type of services. Coinsurance is a percentage that the client pays for each instance of the service. Typically, a client is required to pay  either a copay or coinsurance but very rarely both.

There is one time that the insurer gives you a break. That’s when you reach your maximum out of pocket expenditures (MOOP). In that case copays and coinsurance would no longer be required.

One final term that impacts costs are modality specific session limits. These may be hard or soft. Hard limits cannot be adjusted. Soft limits can be increased with varying degrees of difficulty and likelihood of success.

I know it’s a lot of information. Let’s summarize, make a final point, and then take a break.

Today’s health insurance combines elements of indemnification and managed care. All things being equal, costs increase as choice increases: HMO (least cost, least choice), EPO, POS, PPO, indemnification (most cost, most choice).

Deductibles are how much you must pay before the insurance pays anything. Copays and coinsurance are your ongoing share of the cost.

If you are lucky (or unlucky) enough to spend so much money out of pocket you reach your maximum, you don’t have to pay anymore copays or coinsurance for the rest of the plan year.

Keep track of session limits. For various reasons, providers usually don’t.

A final point. Health insurance is a strange 3 party arrangement.

You, the client, have a contract with the insurer. Indeed, you are the insurers customer. In theory, they work for you—their purpose to pay or reimburse for healthcare services.

Your provider also works for you and answers to you. Your provider always works exclusively for you. You are obligated to pay your provider and/or release your insurance company to do so.

Your provider may or may not have a relationship with your insurer. A participating or in network provider provides behinds the scene services including billing, note and plan submission, and other administrative tasks. A non participating or out of network provider need not provide any service other than a statement when you pay. Creative, as a courtesy, currently provides billing, note submission, authorization requests, and so on, promptly and free of charge.

—Richard Feingold, Co-founder

 

 

 

 

 

 

 

Transdisciplinarianism

Is transdisciplinarianism a real word? First, let’s see what it means.

The 20th Century brought us many great things. And many challenges. The Newtonian physical theories of both the very large and very small were supplanted by General Relativity and Quantum Mechanics. Nuclear technology revolutionized everything from medicine to power generation to war and peace. Aviation and the automobile transformed travel. Computers have transformed most everything from navigation to entertainment.

Science, technology, and information processing drove material progress and had profound social implications and enormous cultural influence. One of the most unfortunate takeaways of this progress was reductionism—the idea that problems could be solved by reducing them to their most basic constituents.

That perspective was often adopted in healthcare. Specialization dominated. Practitioners isolated symptoms, minimized the domain of interest, and treated. Specialists even specialized within specialties. This was further challenged by a medical model that shifted from health and healing to symptomatic diagnosis and characterization and long term pharmacological intervention.

There was the all too true cliché of seeing clients as personifications of their symptoms. Patients referred to by their issues: “Send in the broken arm.” “When am I scheduled to see the bowel obstruction.” I cringe when I hear someone referred to as a “special needs child.” To me, it is a child with special needs or better, a child with differences.

It’s not political correctness, rhetoric, or semantics. It’s fundamental. We must see the child as a unique holistic human being with differences from typical development that inhibit his or her ability to engage the world, to know themselves and feel good about themselves. We must treat the whole child.

And to treat a child holistically, we a need a single integrated plan of care. The services provided must be driven and defined by the unique needs of the child.

So, how do we do that when there are increasing modalities to learn? more and more knowledge necessary to successfully treat the children we see?

It’s by continuing to learn and work as a team. It’s by meeting every day as a team and remaining focused on the unique needs of the child.

That’s transdisciplinarianism: The perspective, belief, and practice that informed treatment must optimally focus on and respond to the holistic needs of the individual and multiple disciplines are combined, integrated, and harmonized for maximum benefit.

Our practice believes so strongly in this approach that we meet as a team one hour every day. Every day. Each child we see requires, deserves, and receives the benefit of our collective expertise. Each child.

Okay, transdisciplinarianism is not a real word yet. I have faith that will become one. In fact, I just added it to my spelling checker dictionary.

What do you think?

 

Health Insurance: Maximizing Benefits (Part 1)

Few people are satisfied with how health insurance serves us. Issues range from the very political (Obamacare good or bad?) to the very practical (will the insurance pay for my child’s service?)

Philosophically, the purpose of insurance is to protect a group of people from uncertain and potentially costly events. While contemporary health insurance maintains that role in terms of catastrophic medical events, it also has  become more and more the manager of our health services.

This trend is problematic and fraught with hazards. Here at Creative we deal with its consequences daily. Many of our clients are constrained and sometimes denied services because of decisions made by administrative and quasi-medical people at insurance companies.

My purpose in this article and others to follow is to help all of us maximize our benefits by knowing the law and asserting our rights, by dealing crisply and smartly with insurance, and by maximizing our benefits and their application.

Important history.

About 4 decades ago during the Nixon administration, Congress passed two laws that set the stage for our current situation. One took power from us and gave it to insurance companies; one took power from employers and gave it to us. The insurance companies have spent the last 40+ years maximizing their profits from all this. They have also done a good job in keeping us from understanding and asserting our rights.

Beginning with the first HMO enabling act in 1973, Congress allowed and encouraged insurance companies to manage health care. Ostensibly, this was so that they could add efficiencies to the markets and balance rising health care costs with collective purchasing power—all for the benefit of the consumer. Further, there was some consideration to reduce medically unnecessary services through mandatory second opinions and peer review.

The next year, through the passage of ERISA, Congress also put employers on notice that when they promised a benefit—such as medical care or pensions—they had to deliver. While the primary motivation of ERISA was protecting against the severe and increasing problem of employer pension default, the inclusion of medical benefits under its protection was prescient and forward thinking—and of great significance to us today. The passage of Affordable Care Act in 2010 extended ERISA protections to government employees and other plans.

This may be a lot to take in. So let’s make one more key point and wrap up Part 1.

Consider a pension. It’s straightforward. You leave the company and at a predetermined time in the future you start getting paid a certain benefit each month (or some other arrangement). What you get paid is determined by the plan.

The company may hire an insurance company (or a bank or brokerage) to administer the pension. That agent may even subcontract part of their function. All that is fine as long as it does not change the amount or the frequency of the benefit. Indeed, any change would be a violation of their fiduciary responsibility; and if they kept money that should have been paid you, they would be guilty of fraud.

Why spend two paragraphs on pensions? Reread them in terms of medical benefits instead pensions. The same principles apply.

We will discuss this further in Part 2.

—Richard Feingold, Co-founder

 

 

Welcome!

A blog is a great opportunity for multi-way conversation. In a topic as important as health services for our children, it’s critical that all ideas are heard and considered, that everyone has an opportunity to contribute. I know what I want to say, and as much as I may enjoy hearing myself talk, it’s more important and beneficial to myself and our practice to hear what you have to say..

When we founded Creative a key goal was an open, transparent, and inquisitive organizational culture—a place to foster and encourage creativity, welcoming and responding to the hard questions, the challenges, and the doubts.

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My warmest regards,

—Richard Feingold, Co-founder