Day: 18 December 2024

“To define yourself is to limit yourself. Without labels you remain the infinite being.” ~Deepak Chopra Living with both ADHD and anxiety feels like trying to navigate life with your mind constantly racing in a thousand directions at once. It’s frustrating and exhausting, and, at times, it feels like success is out of reach. But here’s the truth: success is possible. Even when it feels like your brain is working against you, with the right strategies and support, you can thrive. As a nurse practitioner who has lived with undiagnosed ADHD and anxiety for much of my life, I’ve experienced the struggles that come with both. I’ve been labeled lazy, unteachable, and a lost cause. But I’ve also learned how to break through those labels and find success on my own terms. It’s not easy, but it’s absolutely achievable. The Early Years: ADHD and Anxiety in School Growing up, ADHD wasn’t something people talked about. Kids who had trouble focusing were often written off as lazy or troublemakers. I was one of those kids, but I wasn’t the hyperactive type, so my struggles flew under the radar. My teachers assumed I wasn’t trying hard enough, but the truth was, I was trying as hard as I could. If a subject didn’t grab my interest, my brain simply couldn’t focus. The frustration of not being able to retain information or focus made school incredibly difficult. Teachers labeled me as lazy or unteachable, and those labels stuck. By the time I reached high school, I was so far behind that showing up to class felt pointless. My grades were posted for everyone to see, and every time, I was at the bottom of the list. It felt like the world was constantly reminding me that I was a failure. As my anxiety grew, I started skipping class regularly. Why show up just to feel like I was being judged? I was already seen as the kid who couldn’t keep up, and every time I walked into a classroom, it felt like a reminder of how far behind I was. The anxiety of being judged, combined with my ADHD, made it impossible to succeed in that environment. Hitting Rock Bottom With no support system in place and a constant sense of failure hanging over me, I turned to unhealthy coping mechanisms. Drugs and alcohol became my escape from the pressure, anxiety, and feelings of inadequacy. The constant emotional beatdown from teachers, peers, and my own inner voice was too much to bear. I began to believe that I really was a lost cause. No one seemed to care about my potential, and I certainly didn’t see it myself. Eventually, I was kicked out of my public high school. At the time, it felt like the end of the road for me, but in reality, it was the best thing that could have happened. Finding a New Path: The Alternative School After being kicked out of public high school, I was sent to an alternative school, a place for the so-called “bad kids.” This school had a reputation for being where the rejects went—those who were expected to drop out, end up in jail, or get pregnant. But what I didn’t expect was how this environment would change my life. At the alternative school, the teachers didn’t care about my past failures. They didn’t look down on me for my low grades or judge me for being behind. Instead, they saw my potential. They worked with me one-on-one, offering me the chance to catch up and even get ahead. For the first time in my life, I felt like someone believed in me. One teacher in particular recognized my talent for writing and encouraged me to join the school newsletter. I started taking on more responsibility and eventually became the editor. For the first time, I started to see myself as capable and smart. College and Career: Finding Success Despite ADHD and Anxiety After graduating from the alternative high school, I had a newfound sense of confidence. For the first time, I believed that college might be an option for me. I started at a community college and eventually transferred to a university, where I earned a bachelor’s degree in journalism and communication studies. However, after working in journalism for a while, I realized that it wasn’t my true passion. I pivoted and went back to school to pursue a career in nursing. Earning my associate’s degree in nursing was one of the hardest things I’ve ever done, but it was also the most rewarding. For seven years, I worked in the emergency department, where the fast-paced environment kept my ADHD in check and the constant reminder of life’s fragility put my anxiety in perspective. Managing ADHD and Anxiety in Adulthood While I had found success in my career, my ADHD and anxiety didn’t magically disappear. In fact, they became even more noticeable when I transitioned to working as a nurse practitioner. The COVID-19 pandemic brought an intense level of pressure, and my anxiety skyrocketed. I found myself overthinking every decision, double- and triple-checking my work, and seeking reassurance from colleagues constantly. It became clear that I needed to develop better strategies for managing both my ADHD and anxiety. Through a combination of medication, mindfulness practices, and a strong support system, I’ve been able to keep both in check. What Works for Me: Strategies for Managing ADHD and Anxiety Over the years, I’ve found that managing ADHD and anxiety requires a holistic approach. Medication has been a helpful tool, but it’s not the only answer. I’ve also incorporated practices like meditation, gratitude, and positivity into my daily routine, all of which help me manage my symptoms. Meditation in particular has been a game-changer. It helps me calm my racing thoughts and stay grounded, especially when my anxiety starts to creep in. Practicing gratitude keeps me focused on the positive aspects of my life, which helps counter the negative self-talk that can sometimes accompany

This is part 2 of Jeff Goldsmith’s history of managed care. If you missed it read Part 1 By JEFF GOLDSMITH The late 1990s crash of HMOs opened the door to a major consolidation of the health insurance market controlled largely by national and super-regional health plans. While HMOs by no means disappeared post-backlash, the “movement” begun by Ellwood and Nixon fell far short of national reach. HMOs never established a meaningful presence in the most rapidly growing parts of the US- the Southwest, South and Mid-Atlantic regions, as well as the Northeast. The exemplar, Kaiser Permanente, damaged its financial position with an ill-considered 1990’s (McKinsey-inspired) push to become a “national brand”. Today, over 80% of Kaiser’s 13 million enrollment is still in the West Coast markets where it began 80 years ago!  HMOs Go Public and Roll Up Two little noticed developments accelerated the shift in power from providers to payers. One was the movement of provider sponsored health plans into the public markets. PacifiCare, the most significant hospital sponsored health plan owned by the Lutheran Hospital Society of Southern California, was taken public in 1995. A subsequent merger with FHP health plan destabilized the newly public company.  After PacifiCare crashed post the 1998 Balanced Budget Act cuts, and struggled to refinance its debt, it was acquired by United Healthcare in 2005, bringing with it a huge sophisticated, delegated risk contracting network. United then bought Sierra Health Plan based in Nevada in 2007, including its large captive medical group, its first medical group acquisition. Following these acquisitions, United rolled up PacifiCare’s southern California based at-risk physician groups in the late 00’s, and then capped off with its purchase of HealthCare Partners, the largest of all, 2017 from DaVita in forming the backbone of today’s $110 billion Optum Health.     United’s buying BOTH sides of the delegated risk networks-plan and docs-in high penetration managed care markets is not fully appreciated by most analysts even today.  It has meant that as much as 40% of Optum Health’s revenues, including almost $24 billion in capitated health insurance premiums, come from competitors of United’s health insurance business.   However, of greater strategic significance was Humana’s decision in 1993 to exit the hospital business by spinning its 90 hospitals off as Galen.  Humana’s unsentimental founders, David Jones and Wendell Cherry, concluded that the intense physician push back against their growing health plan meant that their two business were fundamentally incompatible, and they chose to retain ownership of the higher margin and less complex business. Galen hospitals began a lengthy and sad journey through multiple owners-Rick Scott’s ill-starred Columbia/HCA, Tenet, and then multiple others. Today, Humana is the second largest “player” in the Medicare Advantage market, and had a market cap north of $60 billion (until a month or so ago).   HIPAA Sets Stage for 24/7 Electronic Surveillance of Medical Decision Making The other little remarked development provided the technical foundation for a payer controlled care system- the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Up until the mid-1990s, healthcare claims were paper and fax transmitted, costly and unreliable. Though HIPAA is mainly known for its confidentiality protections for patient data, its Administrative Simplification provisions set data standards to encourage electronic submittal and payment of medical claims.  HIPAA encouraged the emergence of electronic data interchange through dedicated T-1 lines, hardwired ancestors of today’s VPNs–high capacity, secure physical links between hospitals and their major payers. HIPAA markedly accelerated the use of electronic data interchange (EDI) in healthcare, to the great advantage of health insurers.   HIPAA spawned a whole ecosystem of small companies who served as financial intermediaries between health insurers and care providers–aggregating, transmitting and processing medical claims and paying  providers for their care.  These companies proliferated during the first Internet investment bubble, which began after Netscape’s historic IPO in 1995.   When the Internet bubble burst in 2000, these companies were sold by their private equity and venture owners in an ensuing multi-year fire sale.  PPO Growth Burns Down the Commercial Rate Structure While the HMO movement faltered, provider-centric delegated-risk capitation gave way to broad panel “preferred provider organization” (PPO) managed care which paid physicians and hospitals a discounted fee-for-service, and overlaid external utilization controls like prior authorization. The PPO movement markedly diluted physician economic power. PPOs were basically an industrialized version of traditional Blue Cross, only without physician or hospital governance input.  PPO health plans threatened to exclude local providers that did not grant them significant discounts. Independent physicians had zero leverage in this transaction. Hospitals who discounted their rates in the panic to avoid being excluded discovered that their pricing concessions yielded no growth in volume or market share, just reduced revenues. This late 1990s pricing panic burned down hospital commercial rate structures in the West and Southwest, as far east as Chicago, Minneapolis and St. Louis, and accelerated the trend to system consolidation.    The ObamaCare Festival of Technocratic Enthusiasm At the same time, Medicare moved aggressively to get providers into a new, less politically inflammatory version of managed care for large regular Medicare market (e.g. the non-Medicare Advantage portion).  The 2010 Affordable Care Act’s main event was to expand health coverage to the working poor through a partial nationalization of the individual insurance market and an aggressive expansion of Medicaid. This coverage expansion was a huge success, bringing new coverage to 30 million Americans.  But in a muted afterthought, recognizing continuing health cost pressure, ObamaCare also sought to revive, for one last time, for regular Medicare,  the Ellwood/Enthoven vision of a transformed,  at-risk care system. Having concluded that the closed panel, capitated integrated care system model could not be reached in a single impossible transformation, as the Clintons attempted and failed to do, it would sow the seeds of capitation through a “managed care” lite model called Accountable Care Organizations.     There were two ACO concessions to the post-HMO backlash environment. First, Medicare patients were not forced into managed care plans (or even told they were in them), and providers would be insulated from downside financial risk for a lengthy period. ACO membership was a statistical construct, not a consensual patient panel; patients would be assigned to ACOs if their primary