Tuesday, January 22, 2008


Just thought I'd add a note of hope to the downer I just posted.

Senator Karen Keiser, representing the 33rd Legislative District in the Washington Senate, and Chair of the Health & Long-term Care Committee, has introduced SB 6221, available for review here, which would create a system for universal healthcare insurance coverage in our state. There's a nice review of the issue, and the history of healthcare reform in Washington, in this Puget Sound Business Journal article.

One of the interesting points in the preamble to the bill is the statement: "In 2007, the average annual premium for family coverage was twelve thousand dollars, of which over three thousand dollars are paid by the worker." There are a number of similar interesting statistics noted.

So, thank you Senator Keiser, for your work. And thanks for providing me with some hope...

HealthCare Meltdown 101: The Emergency Room...

As we lingered after dinner with our dearest friends this weekend, we started talking about politics and health care. And, one of the first things spoken round the kitchen table was "We have great healthcare in America." And so began a converation about just some of the myths that Dr. LeBow debunks in his book: Health Care Meltdown: Confronting the Myths and Fixing our Failing System.

In the first chapter of the book, Dr. LeBow starts with these two quotes:
"America has the best health care system in the world." - Many American politicians


"The moon is made of green cheese." - Anonymous, 16th century, likely a dairyman

The first myth that Dr. LeBow tackles is one that I've heard even recently: "Everybody has access to care through the emergency room".

This myth was recently stated as fact by our own President, George W. Bush, a man whose home state ranks #1 in the number and percentage of uninsured, as noted by many sources including this review of US Census Bureau statistics. In a speech last July, the president made this bonehead statement:

“The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you just go to an emergency room.”

There's a great commentary on this statement here.

This was the topic of a recent article in the Puget Sound Business Journal. In the article, one of my old partners in practice, Dr. Brian Wicks, appears to bemoan the fact that our government put in place laws that make it illegal for hospitals to turn away patients in the case of an emergency life-threatening condition or active labor, the EMTALA act. To quote Dr. Wicks:

"Anybody who walks into an emergency room will get taken care of, (and) that's part of the problem, because people use the emergency room instead of going to a primary care doctor."

So, what's wrong with this position? Well, there are a number of issues. The one that strikes me most squarely in the face is that (some) patients are not getting care when they present to the emergency department. They are, in fact, being turned away. Oh, not so that it would violate EMTALA. But, let me tell you a story, a true story.

A young man, while working at his construction job, injures his hand. His right hand; he's right-handed. He presents to the emergency department for care. (We'd all do the same thing, wouldn't we? Surely, this isn't the inappropriate access to which Dr. Wicks referred...) He is seen by the emergency department physician, and xrays are obtained. He has a comminuted fracture of the hand, a fracture that is thought to be beyond the scope of practice for a family physician, and would most commonly be treated with orthopedic surgery. Good thing we have a hand surgeon in our community, one might think. But, unfortuately, the hand surgeon is not on call today. So, the emergency department physician makes a referral to the orthopedic surgeon on call. (Our community hospital in fact keeps orthopedic surgeons "on retainer" by paying them to be available to take these sorts of cases. But, that's another topic.) The patient is given instructions to call their office the following day to schedule an appointment. So far, so good.

Well, when the patient calls the next day, he is told by the office staff that he cannot schedule an appointment. He sees one of my partners in our current practice, who hears the story and has our staff call on the patient's behalf. The answer remains the same, "Our practice doesn't take his insurance." (Oh, but I thought the hospital was paying you to be on call for the emergency department?...)

In this situation, which is not unique in our experience, the patient certainly runs the risk of deformity, chronic pain, and disability, because he didn't have the right "credentials" when he presented to the emergency room. He is not alone; the Kaiser Family Foundation reviews similar risk in the report entitled "Sicker and Poorer: The Consequences of Being Uninsured." And, the Institue of Medicine estimates that 18,000 adults die each year because of lack of insurance, in this report, despite this safety net of emergency department care.

So, while the emergency department didn't literally turn this patient away, the result was the same - the patient went without the care he needed. And, clearly this care is outside the scope of primary care. So, Mr. Bush, what would you have him do? So, Dr. Wicks, which of your partners in the community will see this man? And, if it were your brother, your father, your neighbor, what would you want for him?

I enjoy the benefit of close and caring friends. And, I think we came to the right conclusion at the end of our brief talk - the world has a hard heart toward others.

Friday, January 18, 2008

Long week...

It's been a long week. I've been on call for our practice, which means that I'm responsible for all the adults and children requiring hospital care from our practice. And it's been, unfortunately, a typical week - busy, with some very ill patients, many of whom are uninsured or "underinsured".

I am caring for a middle-aged woman who presents with chest pain, so she gets admitted to me to be sure that she hasn't had a heart attack. (yeah, there are cardiologists in our hospital, but they don't do this kind of work...) And, oh by the way, she is actively suicidal. (yeah, there are psychiatrists in our hospital, but they don't do this kind of work... sensing a theme here?) I was able to have her seen by one of our psychiatrists, who started her on therapy. She has no evidence of heart disease, and so now she sits on the medical unit due to her depression and suicidality. (We do have a psychiatric unit in our hospital, but... you know what I'm gonna say! - When I inquired about her being cared for on the psychiatric unit, the immediate response was, "Well, she's uninsured, so...".)

I'm seeing a young man, a man who works hard in a physically-demanding job. He's been ill for more than a month. He went to the Emergency Room when he got sick, and they treated him for pneumonia. He was asked to follow up with one of my partners in our office, but he couldn't afford it. (We are not a free clinic, but we charge people based upon their ability to pay, so the fee for the office visit may be as low as $20.) Since he couldn't afford to see us in the office, he had to go back to the emergency department a few days ago, having gotten more and more sick. He has been in the hospital all week with a severe pneumonia. He's worried about how long he might be off work, since if he doesn't work, he doesn't get paid. He'll need a month of antibiotics, which would cost him only about $350 at a local pharmacy. "That's almost what I pay for rent," he says. The owner of the small business for which he works doesn't offer him health insurance; he's been on a waiting list for Washington Basic Health Plan for two years. Let's see, two emergency department visits, two CT scans, four or five chest xrays, inpatient care for ~ a week, with antibiotics and oxygen.... that's likely to be, I would guess, $20,000. How many of us can cough that up? How long will he be paying for this? Oh, and he doesn't smoke. This clearly isn't a case of an error in judgment, "personal accountability" - it could have been any of us with this course.

You know, you can find some information now on the web showing the costs of care for various diagnoses at your local hospital. At this site, I see that the average cost for my local non-profit community hospital. Uncomplicated pneumonia: $8,100-11,400 - "33% lower than national average." This young man surely has costs higher than this average, given the severity of his disease and the extra tests and time he's had to have. I'm also interested to see that the website indicates the services available at the hospital, starting with Behavioral Health / Mental Health / Substance Abuse Services. It looks like they forgot to add the asterisk, which points to the fine print: "...some services only available if you have desireable insurance status, and not available at all to the uninsured in our community."

Let me add this comment here. The words here are my own ramblings, and do not necessarily reflect the opinion of my employer or those with whom I work.

Well, back to work. I have to see some more patients after my lunch break.

Friday, January 11, 2008

Advocacy 101 Workshop

Suzette works on her "elevator speech" for an advocacy workshop we had at our Center. Suzette is one of my partners in practice, a Physician Assistant with a compassionate heart.

An "elevator speech" is a short list of "talking points" that you can use to tell your story in the short time of an elevator ride. Mine goes something like:

"I'm a family physician.I work at a Health Center, which is a private not-for-profit medical and dental practice owned by the community and run by a volunteer Board of Directors, the majority of which are patients we serve. The community started our Center twenty years ago, with the mission of seeing patients who can't find care elsewhere. I work there because I think that access to health care is a right of every human being."

What's your "elevator speech"? Why do you do what you do?

Advocacy 101 Workshop
Originally uploaded by Doug Felts

Tuesday, January 8, 2008

Everyday stories...

I'm still here! And, so is the work...

We have been implementing an EMR in our practice, or rather, RE-implementing. But that's another story, for another blog. And, in the middle of that, I'm still seeing patients a couple of days a week, at least.

So, I thought I'd share a few of the stories from the past few weeks. I think these stories help to show some of the struggles we are facing...

I am seeing a middle-aged guy for wound care, on a nearly every-day basis. ("Middle-aged" - he was born the same year I was!) He has suffered for years from gastroesophageal reflux disease - "heartburn". To the point that he was best treated with surgery. So, he had his surgery in November, and developed an infection at the wound site. The infection resulted in a four-inch long dehiscence - the surgical site opened up. This wound was about 3 inches deep. He was treated in the hospital for a while, by his surgeon, and then sent to a nursing home; he left there when he became concerned about medical errors. He was sent back to our clinic by the wound care clinic at our local (nonprofit) hospital -they didn't "take his insurance", which is Medicaid. So, I've been seeing him, in my office, nearly every day, with my partners helping on weekends, so that we can change his dressings. Looks like it'll take another couple of weeks for his wound to heal. The other day, he thanked me with a small gift, a bottle of specialty grape juice from his hometown in California. He told me that he had the impression that I was the only one who cared about him, everyone else was trying to avoid seeing him. As a family doc, and one who cares for the poor, I can say that it seems that I am often taking care of problems that others don't/won't care for...

I met a young woman a couple of weeks ago. She had been stricken by seizures about fifteen months ago. She was transferred from our local hospital to the regional medical center of a local university, and was started on medication for her epilepsy. She then enjoyed several months without seizures. This care was funded by Medicaid. Well, she came to see me because she is now uninsured. She is no longer eligible for Medicaid. You see, she hasn't had any more seizures, so she doesn't have a medical condition warranting ongoing insurance coverage. All she has to do is keep taking her medication. Oh, yeah, there is one thing. The medication costs $700 per month. And she works full-time at a minimum wage job. Let's see, that's ~$9/hour for 40 hours per week, 4 weeks a month - that's about $ 1440 per month. So, it seems she is being given a choice - pay for her meds, and skip "luxury items" in her budget, or quit her job, become unemployed, and therefore qualify for help once again...

I was on call for our practice last weekend. I got a call from the Emergency Department physician Sunday afternoon about a patient he was seeing. She was experiencing "the worst headache of her life", and had developed right facial and right arm weakness. He was calling me because there is no neurologist available to him - the neurologists in our community have elected NOT to be available for uninsured patients who present in need to the local hospital. So, he was going to send her home, and hoped that I could help her get in to see a neurologist "somewhere". All we can do is ask...

I sat with a young man in my office yesterday. He has had ongoing back pain for years, and finally got an MRI done a few months ago. He was insured at the time, so didn't imagine that he'd be burdened by the cost of the test. Well, when he presented to the radiology suite, he was told he was too big to fit in the MRI machine. But, they could do the test at their other facility, about seven miles away. He had driven himself to the appointment, and thought it was odd that they had chosen to transport him by ambulance to and from the other facility. He never imagined that, since it wasn't "medically necessary", the insurance company would refuse to pay for the ambulance ride, and he would have a $3000 bill - that's only $214 per mile...

I'm listening with interest as "healthcare reform" is discussed at rallies and debates by our presidential candidates. But, I'm not sure any of them get it. We don't need a better set of incentives, as promised by the "Pay for Performance" movement. We need more compassion for our neighbors, and less concern for the stockholders of the pharmaceutical and healthcare insurance companies.