The Tale of Two Women

            Although I closed my practice of medicine, more than three years ago, two questions continue to haunt me. The first, “Is my life not worth two thousand dollars?”, came from a thirtyish African-American, woman, night supervisor in a fast-food restaurant in Atlanta. The second “Should they have spent so much money on me?” come from a thirty-two year old white woman in Boston.  During my thirty years of caring for patients, never had any so concisely conveyed what it is to live in America without health insurance.

            Several years ago, my wife and I traveled to Atlanta to volunteer at a one-day free medical clinic for anyone without health insurance.   As a psychiatrist, my wife was assigned to ‘Behavioral Health’ while I was assigned to General Medicine. Shortly after the clinic opened, my wife arrived at my cubical, wanting to see me. As I stepped outside the curtain after asking the patient I was attending to excuse me, I saw my wife was un-nerved and angry.  “What’s going on?” I asked.

            “Can you believe this? I am seeing a young woman sent to Behavioral Health because the triage physician noted she was severely agitated when she registered. They got that right, but she does not have a psychological problem. She is a neatly dressed thirtyish year old African-American woman working both a day and night part-time job neither giving her health insurance. For several months she experienced right lower side pelvic pain. After three months of wishing the pain would go away, she withdrew all of her savings just yesterday to see a gynecologist. After describing the pain to the doctor, he did a quick exam and told her she would need an ultrasound. He could perform it in his office. Her last dollar paid for the ultrasound that showed a possibly cancerous right ovarian mass. She would need a CT scan and possibly a biopsy to determine if it was. ‘How much would that cost?’ she asked.’ The doctor, indifferently, quoted her two thousand dollars. ‘I’ll be dead before I can save that amount she responded in amazement’”

            “Not having a physician, health insurance or the money for another doctor’s appointment, she did not know how to get the care she was told she needed. Fortuitously she had read about this one-day free medical clinic. Doubtful that the clinic would be helpful, but hoping otherwise, following her night shift, she changed out of her night supervisor uniform and dressed for the clinic.”

            “She was an emotional wreck when she arrived unable to say why she had come. The nurses quickly saw she was hysterical and triaged her to me in ‘Behavioral Health’ where, convinced she was facing death, she asked ‘Is my life not worth two thousand dollars?’ Will you come see her with me? my wife asked.

            Excusing myself from my station, I walked across the expanse of the Convention Hall. By the time I arrived, the woman had composed herself and was able to repeat her story. Knowing that hospitals are obliged to provide care for patients unable to pay, we arranged for her to be seen, free, at one of Atlanta’s medical centers.   My wife and I feel good about having helped, but remain overcome by the question, “Is my Life not Worth Two Thousand dollars.”

            A few years later, while driving to the hospital, I heard another haunting story of young college graduate recently moved to Massachusetts to get a job and begin paying off her student loans. Her job did not provide any benefits and she did not have the funds to purchase health insurance. But she was in good health, and felt invincible. When bruises first appeared spontaneously on her lower legs, she refused to see a physician fearing a bill she could not pay. Quickly, the bruising spread to her chest, a and friend, urged her to see a physician. She did. The diagnosis was acute leukemia. Without sophisticated and expensive treatment, she likely would die.

            Fortuitously she lived in Massachusetts and qualified for the state’s universal health coverage that gave her access to the most sophisticated treatments including a bone marrow transplant. A million dollars later she was alive and again working to pay off her student loans but questions if saving her life was worth so much tax-payer money.

            When I think back over my medical career almost fifty years age, the stories of these two young women represent all that is good and all that is bad in my profession. On the one hand, are the formidable advances – new medicines, new treatments,  imaging the human body to one-centimeter resolutions, sequencing the human genome and curing incurable diseases. The best of the best offering hope to those who would have died fifty years ago, now live because of these achievements.  On the other hand is recognizing that those who would have died fifty years ago because they could not access health care, continue to die today despite these advancements. How can it be that of these women, both citizens of the United States, one survived her disease because she lived in Massachusetts that provides health care for nearly all of its residents subsidizing those who cannot afford it, and the other may have died because she lived in Georgia where almost 20% of its residents are not insured and there is no public program to provide coverage for those who cannot afford insurance. Much has been done, much more needs to be done.

Genetic test to Screen for Cervical cancer - whose benefit?

A genetic test to screen for cervical cancer is an exciting development. However, at a time when cost is  central  to providing equitable, affordable and accessible care, it is unfortunate that the FDA approved the genetic test without a comparative judgment. There are important questions that should be answered before the Pap test that has been so effective in shrinking the incidence and mortality of cervical cancer is replaced by a more expensive but possibly no more effective test. If, as mentioned in Monday's editorial, the cost will be twice that of a Pap test, will it detect that many more cancers? Will its increased cost discourage women, particularly of lower socioeconomic status, to avoid screening? Without answers to these questions, among others, how will we know if the genetic test is a major advance for women’s health or an advance for the well being of its producers? 

It Is Not Enough

The following tragedy was recently reported by many newspapers. As described, the care that this young man received was poorly handled.  The case demonstrates the chasm between the technology of medical care in 2012 and the system in which it is provided The response from the major medical center where he was treated in the middle a major city was inadequate.  Such a vacuous correction confirms that the hospitals responsible for providing the care do not understand the problem.

NYU Langone Medical Center announced on Wednesday significant changes in its procedures after the death by septic shock of a 12-year-old boy who was sent home from the center with fever and a rapid heart rate.
Three hours after the boy, Rory Staunton, left the emergency room, a laboratory test showed that his blood had extraordinarily high levels of cells associated with bacterial infections. He subsequently went into shock and experienced organ failure, and died three days later, on April 1. His parents said they were not told about the lab results and were unaware of how seriously ill their son was, having been assured that he was suffering from a typical stomach bug.
In a statement, the hospital said that emergency physicians and nurses would be “immediately notified of certain lab results suggestive of serious infection, such as elevated band counts.” Rory Staunton’s bands, or a type of white blood cell, were nearly five times as high as a normal level.
The hospital has developed a new checklist to ensure that a doctor and nurse have conducted “a final review of all critical lab results and patient vital signs” before a patient leaves, Lisa Greiner, a spokeswoman, said in the statement.
“In the unlikely occurrence that a clinically relevant test is only available after the patient is discharged from the E.D., the patient will be called, and the information will be shared with referring physician,” Ms. Greiner said.
The family pediatrician, who sent Rory to the hospital to be given fluids for dehydration, said she did not know about the blood work.
Ms. Greiner said the steps were taken in direct response to Rory’s death.
“Keeping our patients safe is our first priority, and we want to prevent this situation from happening again,” she said. 

It is not enough to change hospital procedures how a critical laboratory value is handled to prevent other Rory Stautons from needless deaths. It is baffling that knowledgeable people who administer major medical facilities, such as NYU Langone Medical Center, believe a simplistic checklist can solve such a complex problem. This might have been an adequate correction seventy-five years ago, but not in an era of technology capable of communicating  with a man on the moon.

I entered the medicinal profession fifty years ago and have witnessed technological discoveries that transformed how we diagnose and treat patients. In contrast, during the same time there have been minimal advances in how physicians share clinical data. Failure to attend to how physicians communicate has lead to unnecessary loss of lives as well as to redundancy and excessive cost.

Medicine is not a fail-safe profession. There always will be patients who do not respond to treatments and others whose symptoms we cannot translate. There may even be clinical data that is lost. However, no patient should suffer because we have neglected to modernize our communications. Requesting clinical data to assist diagnosing our patients’ illness and then not use a critical result has no place in an age of robotic surgery, facial transplants, or gene therapy. The imbalance between technological advances and outdated methods of communication is glaring. It is a challenge that cannot be resolved with  ‘new checklist’.

It is one thing for patients to await a cure for advanced coronary heart disease or metastatic tic cancer. They should not have to wait for our profession to stumble its way to effective communication.

Vultures in the Emergency Room

Once again insurance companies tighten access to healthcare . Now it is in emergency room where debt collectors disguised as nurses or doctors or other hospital employees, intrude on patients asking for payment before getting care.  Sometimes one may be encosted on route from parking lot to the emergency room.

These new 'providers' are not actually employed by the insurance companies, but they are proxies for the insurers. According to the front page of today's NYT, some hospitals contract with debt collector agencies to request payment upfront for emergency services. If you have an outstanding bill, payment may be required before receiving emergency services. Somehow your medical bills are abled to be accessed by the collectors.

Although the debt collectors are not employees of the insurance companies, they are the root cause.  Many working Americans cannot afford to purchase health insurance. Some are self employed and cannot afford the enormous premiums for an individual or family policy. For some, their employer does not provide health benefits or does not give the person sufficient hours to qualify for health benefits. Since the hospitals are obligated to provide care for all people who arrive at the door and some cannot pay for care or have no or poor insurance coverage, they are caught in the middle. The hospitals are tight for money so they hire debt collectors, disguise them in doctor or nurse attire and set them off to prey on those who least can afford to pay. The thought of being 'asked' for payment when seeking emergency care is enough to intimidate patients are intimidated who then may avoid seeking care until their illness has progressed to point that it cannot be ignored. At that point, care is many times more expensive and much less effective.

What has our method of healthcare come to? Are we so small minded to allow such practices to add insult to injury of our most vulnerable fellow citizens?

The free market has had many decades to resolve this inequality. It has not done it. Therefore, it is unlike that they will do it any time soon. Do we really want to see ourselves as so unconcerned about our neighbors?

If we are honest with ourselves, we know this is unlikely to get better without getting the 'forces of the market place' out of the emergency room and the physicians' offices.

You Have Already Paid!

Let's understand that we already are paying for those patients who have no health insurance and because they have no insurance, and have most likely not seen a physician for years, we are probably paying more for their care than we will under President Obama's Affordable Care Act. How could this be, you may ask?

Let's just consider a 57 yr old man who has not had health insurance for several years either because he is independently employed or because his employer has not given him sufficient hours to qualify for health benefits. He has not had the money to pay out of pocket to receive any routine care. Previously, when he he was able to afford insurance, he was being treated for hypertension and diabetes. 

Now he develops an acute chest pain and calls 911 and is taken to the emergency of the closest hospital. It is very likely, that he is in this situation in part because his blood pressure  and diabetes are completely uncontrolled and have been since he was last able to see a doctor - five or sic years ago.

He is admitted to the coronary care unit with an acute coronary syndrome. Cardiac cathiterzation is done and he is taken for  emergency coronary by-pass surgery. After five days in the surgical intensive care unit he is transferred to a step down unit and discharged three days later. He leaves the hospital with blood pressure, cholesterol, and anti platelet medications with a bill of $75,000.

Someone has to pay. It may be 'free' to the patient, but the hospital will not absorb this charge. The hospital will look to the city, county, state  to offset the charges. The city, county and state will then ook to their constituents for these funds and this is called taxes in some form or another.

Under the President's plan should this same patient get admitted to the hospital with the identical symptoms and problems, the same treatment would be given and the charges would also be $55,000. The only thing that would change is that the federal government would pay. How does the federal government obtain the money to pay? It collects taxes.

The care administered to the patient does not impact on the care available to  you. You will not pay more for this care, in fact you may pay less, because under the President's plan the patient will have insurance that will allow him  to receive ambulatory care to control the patient's risk factors and therefore reduce the chances of the patient requiring emergency cardiac by-pass surgery.

So let's understand that already, before the President's reforms go into effect,  everyone with health insurance is already paying for the hospital care of those without insurance. Let's understand that the impact on those with insurance of caring for those without health insurance is already occurring because the care is already given.

It is not an issue of paying more or getting less. Let's be honest with ourselves.

Oh, and if you say that you do not want to pay taxes to our cities, counties and states so they can pay for the care of the uninsured, think again. The hospital will still deliver  the care, at least until they have no funds and can no longer remain open. Then when it comes your time to need the hospital, it will not be there and you may have to travel longer distances to receive your own emergency care. It may take longer to get to the hospital and this may just be too long for your heart to "hold on" until the doctors and nurses can start caring for you. In the extra time it takes to get to the emergency room, your heart vessels may progress from partial to complete closure and you may not be able to benefit from bypass surgery.  Distance is time and time is critical in emergency - do you really want to even think about being in that position? 

You can't mean it!

Let's get serious! The Heath care debate has begun anew as the 2012 election approaches and the distortions of the politicians and selfishness of the electorate are becoming loader. I don't get it. Are we, as a nation, so selfish that we can not find it in our hearts and pocketbooks, to extend access to health care to the 16% of our fellow Americans? Are the cheers of 'let him die' that bellowed from the audience of the second debate of presidential candidates representative of the majority of us? I doubt it. However, the rest of us, beginning with the potential leaders of our country remain silent. In this debate, there can be no silent bystanders. Those of us who cringed when we heard those heartless people pronounce a death sentence for a hypothetical fellow citizen, have not raised our voices in support of the small, but very significant, changes to our health 'system', established by President Obama's Affordable Health Act. As with any social change, it is vital to have perspective. The five day work week and the eight hour day were not the first improvements to our labor laws, nor was the voting rights act the first achievement in the struggle for the civil rights of Afro-Americans. History is important! It is not so much a question whether the Affordable Care Act went far enough. It is a question of whether we will fight to support this step and be able to improve on. All of the possible future presidents of this country who were on the stage when the audience cheered to let the person who did not purchase health insurance die were silent. Images of a Roman amphitheater spun through my head! 'But we can't afford it!' Nonsense. We have been paying for the costs of the uninsured all along. Come on! Do you really believe the care the uninsured receive when they end up in the hospital, are not paid for? Of course they are. If it is not from a federal program, it is from the state, or city or county all entities we support with taxes in some form. Again why do those who understand the basic function of government, not stand firm and loud and speak up? Lastly I have to say something about taxes. They are what allows the wheels of government move similar to the oil we use to lubricate our cars. When the Oil is low, I believe we all know that if we do not fill up on oil, our car will not continue to run, and if we are foolish enough to drive when the oil meter flashes red, the cost of repair will overshadow the cost of a quart if oil like an elephant does a mouse. Arguing that we cannot afford to pay for health care for the uninsured and under-insured may save you 'chump change' but your children and grandchildren will need to pay with real money, very real. But who cares about them, particularly if they for some reason, do not purchase health insurance.

Speak the Truth

Opposing the implementation of President Obama's Affordable Care Act, has become the touchstone of the Republican party. They resist any progress to implement this act  that will provide health insurance to over 25 million Americans, who until it is fully enacted, have no health insurance and therefore no access to care.  American citizens who have no insurance have no doctor and therefore receive no care. I have witnessed this over and over again as a volunteering physician at  eight free medical clinics staged across the country and it has been confirmed in the Commonwealth Fund's latest biennial health insurance survey. But facts as these do not deter New York state senator Gregory R Ball from opposing this legislature as his 'Republican duty'. Could we ask what is his duty to the citizens of New York state whose welfare he is pledged to uphold? 

The candidates who seek the presidency of our country boast that this bill is harmful and a step toward a socialist state. The governor of Texas, Mr Rick Perry, shows no shame that his state has the greatest percent of his citizens without health insurance and therefore without access to care. He claims “Well, I’ll tell you what the people in the state of Texas don’t want: They don’t want a health care plan like what Governor Romney put in place in Massachusetts. What they would like to see is the federal government get out of their business.” 

As a physician who has practiced primary care for nearly 40 years, I have never once had a patient complain in any way about Medicare or show any interest in surrendering their Medicare card. Could the Texas governor please tell the truth? Would those who moderate these 'debates' please challenge him and his fellow Republicans to tell the truth about health care in this country? Would they please challenge these would be presidents what evidence they could possibly show that the Affordable Care Act will lead to death panels?  They have it so backwards. Our health system has death panels now. They can be seen among all those without health insurance.  I also have been a participating physician in Massachusetts health reform and have witnessed time and time again the enormous benefits that it provides its citizens. The medical services I have been able to provide to patients with Massachusetts' health insurance, have allowed many to regain self respect, return to meaningful work, and become tax payers.

What does it say about our country when we allow politicians to promote un-truths and use these lies as stepping stones to higher office? What does it say about us as a community when we do not provide health insurance to all of our citizens while allowing those who earn millions of dollars each year to pay little or no tax?

Speak out to falsehood.

Ralph Freidin, MD

Sept 2011