Thursday, April 30, 2009

Did you hear the president talk about us?

As I was driving home last evening, I was listening to the President's press conference.  And, in response to a question about the disproportionate suffering in the Great Recession associated with race, I heard the President mention us:  

"When we put in place additional dollars for community health centers to ensure that people are still getting the help that they need..."

So, the President notes that we are "ensuring" people get the help they need.  That sounds like a value system I can identify with! 

But, I'm afraid I might be seeing the President showing that even he is a bit out of touch with our reality.

Here's the scoop - the Economic Stimulus Package did contain provisions to provide additional support for Community Health Centers, who are facing increased demand for services across the country.  And, we've been able to get a promise for our piece of that... let's see, the whole stimulus package was how much, $700,000,000,000?  I must admit, I can't keep track of the total.  And, we will get our piece - $130,000 a year for two years! 

But, we know that we're seeing increasing demand.  And, this webpage explains that in our state, the Community Health Centers will be the primary recipients of a $1,000,000,000 state funding cut.  
  • Washington's uninsured will increased by 150,000 people, to nearly 900,000 by 2010.  
  • 35,000 people will be kicked out of the Basic Health Plan, and will become uninsured.  
  • A program called "General Assistance to the Unemployable" (GAU) will be cut by $43,000,000.  These disabled and chronically-ill patients will see their monthly income cut to $136.  (Yes, one hundred thirty six dollars!)  
And, who's going to see all these uninsured?  Why, the Community Health Centers, of course.  After all, that's what the President said!  

Clearly, we can't make up our share of a $1,000,000,000 loss by the "influx" of $260,000 over two years!  

I'm sorry Mr. President.  That's not the change I had in mind!

Sunday, April 26, 2009

"Federal Government Declares Public Health Emergency"

Did you see the headlines this weekend? We are in a declared public health emergency! In fact, this emergency is capturing the attention of our federal government, right up to the White House.

When I heard the news, as part of the "safety net" of providers who receive emergency notification from the public health system, I was struck by the importance of this notice... 20 people in the US have been affected, and ~85 Mexican citizens.

And, then, I got a bit angry. The other event, the real emergency, was the latest Washington State budget, which puts 10's of thousands of our neighbors at health risk. And, no one seems to even notice.

I have the privilege of working with a team of dedicated people, who have turned from other, usually more lucrative, career paths in order to serve the least in our community. That privilege is supported by our work seeing patients who are covered by the state Medicaid program and the federal Medicare program; these are patients who are nearly always turned away from traditional (read: "for profit") medical practices in our community. And, as part of the response to the budget crisis, not only are we (the state of Washington) planning to
  1. reduce the number of people covered by the state Medicaid program (and therefore, making them uninsured), we are also
  2. reducing the support for the "safety net" providers, including non-profit Community Health Centers, like mine.
(And, to be clear, where do you think those uninsured patients are going to go for care? To the local for-profit group practice, which expects a deposit of nearly $200 before an office visit? They will defer care until it becomes an emergency, or they will come to my practice, which remains "the last open door" for them for routine, chronic and preventive care.)
We are also reducing access to affordable health insurance for individuals, reducing support for the services of the elderly and disabled.
You can't turn on the radio or the TV without seeing information about the growing concern regarding the swine flu. (My favorite report is that Israel has renamed the illness, since swine are not kosher! Talk about political correctness! Oy Vey!) But, where's the concern, where's the outrage about the tens of thousands, in Washington State alone, of single moms, young families, the elderly, the disabled, who will go without needed health and social services in this "economic pandemic"? There's barely a mention of it on the local news, and little on the national perspective. (You can read the summary on the Washington State legislature website: )
Well, back to work... not only do we need to figure out how to see more patients with less resources, now we have to prepare to assist the community's response in preparation for the swine flu, err, I mean "Mexican flu" outbreak, should it come to our state...

Tuesday, April 21, 2009

How Health Savings Accounts Lead to Wiser Health Care Choices

I thought I'd share this cartoon from Michaela Reed, seen on Flickr.

Take a look at the cartoon, and at the comments - it's still so concerning that people are so misinformed about the realities of health care in America.

One comment says "just go the Emergency Room." And, gosh, who do you think will absorb the cost, if the patient can't pay? (Answer - those who CAN pay, by increased insurance premiums and higher bills!)

Thursday, April 9, 2009

"You think YOU'VE got a headache!"...

You know, as the conversation about America's heatlhcare "system" goes on, I'm struck by some of the standards of practice that we've all engaged in. When I put "system" in quotes, I mean to imply that we don't have a system - certainly one of the criticisms of health care in America is that there is little coordination of care among different providers, different settings ... let me tell you a typical story about that.

This week, I saw a young man in our Community Health Center. He's unemployed, and living with his father. He is uninsured, and we are able to see him on a sliding scale basis, charging him "according to his ability to pay." He tells me that he is here because he had a prescription from an emergency room visit a few months ago, which he'd like to have filled in our pharmacy.

I spent some time getting to know a bit about him, and reviewed the history about his headache. He notes that this seems to be worse when he's around dust. Some further conversation and examination confirms my impression that he has an allergic condition. No big deal; I know how to treat that.

Oh, but what about that prescription? He was seen in an Emergency Department at a well-respected hospital in Seattle. And, he tells me that he had a sinus infection. I just got the notes to review...

So, with a story similar to what he related to me, the ED physician did the following tests:
  • CBC with differential
  • Complete metabolic panel
  • Urinalysis
  • Blood culture
  • Sedimentation rate
  • C-reactive protein
  • amylase and lipase
  • CT-scan of his head
  • Total cost: ???

Gosh, am I just a bad doctor? I didn't even consider any of those tests! In fact, I'm not even smart enough to figure out how ordering amylase and lipase levels, often used to evaluate abdominal pain due to pancreatitis, would relate to the assessment of a patient with a headache! I guess I need to watch "House" more often!

And, the prescription? Well, it was for:

  • Augmentin - an antibiotic [approx retail price from = $145.99]
  • Nexium - a proton pump inhibitor, to reduce stomach acid [ARP = $176.01]
  • Beconase AQ - a steroid nasal spray [ARP = $149.32]
  • Fiorinal - a migraine headache medicine [ARP = ~$45]
  • Total cost: $516.32

So, this uninsured young man saw me for a few minutes. I charged him $20 for the visit, and our pharmacy charged him $15 for the nasal spray.

What do you think that Emergency Department visit cost? All those tests, the highly-trained ED physician? Am I just an incompetent quack, because I have the confidence in my own skills to make a diagnosis and begin treatment without any of that stuff? After all, I just listened, mostly...

As our Administration wrestles with healthcare reform, this case illustrates too much about what's wrong with our "system"... overtesting, overtreating, overutilization. Money spent in the ED which could have been used to address the healthcare needs of many more in the primary care setting, including immunizing kids, providing dental care, managing chronic disease. Misaligned incentives and muddled motivations.

I wonder how his headache is? I'm getting one just thinking about it all...