Compensating Physicians for End of Life Decisions - not Ending Life

Once again those who oppose Presidents Obama's initiative to improve our health system are creating anxiety and fear by crassly labeling as "death panels" time spent by patients and their physicians discussing 'end of life decisions'. Such conversations, for primary care physicians such as myself, are part and parcel of our practice. Longitudinal care is particularly unique to our specialty. It is appropriate and expected that people whom we have cared for years, sometimes decades, while they were enjoying good health, and death was a nebulous abstract, look to us to coach them thru the maze of complex, trying, and uncomfortable efforts to ‘treat’ their untreatable illnesses. They look to the physician they have trusted their health for years to decide when treatment no longer is beneficial or desired.

These conversations cannot be complete if postponed until the final hospital admission. There is not enough time. By then the patient who is too ill to express wishes for the care they want, and too weak to articulate their choices to the unfamiliar physicians whose priority is selecting treatments to retard or control, but rarely cure, the illness. Under these circumstances, patients have little choice but to defer choices of treatment to doctors whom they barely know.

To equate these intimate conversations to death panels is to extract all dignity from the process of dying. Those who suggest that physicians who have these conversations with their patients are ‘death panels’ not only disparages the physicians and the medical community, but more importantly, negates patients their right to decide the manner in which they wish to have their life end.

Re-embursing physicians for time spent in these discussions will encourage physicians to allocate their time and resources to assist their patients with these most difficulty medical decisions. It is only when a patient encounter is specifically committed to this most personal issue that the patient has the opportunity to express his/her desires and the physician has the necessary time to listen. Without these opportunities, patients will be committed to a death that is too frequently postponed to a time when there is no honor to life or dignity in death.

Bread Lines then, Health Lines Now

Three weeks ago, I traveled to Charlotte to volunteer as physician at my seventh (Little Rock, Kansas City, Hartford, Atlanta, Washington DC, New Orleans) free medical clinic for people without health insurance. As previously, there were over 1000 people cared for during the one day clinic. It has now been a full year since I attended my first clinic. Except for Kansas City and New Orleans that were two day clinics, each of these clinics have been for one day. Simply, I taken nine days from my own primary care practice to participate with other providers volunteering their time to care for over 9000 patients none of whom had health insurance and most had the chronic illness of adult Americans ( diabetes, hypertension, hyperlipidemia, coronary heart disease, obesity and arthritis) but had not seen a physician for more than a year even though most had been prescribed several medication by the last physician they had seen.

They arrived with bottles of medications empty because they could not afford to refill them or could not afford a doctor’s appointment to re-write the prescriptions. The stories of the residents of Charlotte were identical to those of the other cities that had hosted the other clinics. They either were self employed and could not afford health insurance for themselves or their family; they had lost their jobs and with that lost their health insurance; or they had part time or temporary jobs that did not provide health benefits.

As if rehearsed, the patients at Charlotte, explained the reason they had not seen a physician in such a long time with a ‘mantra’ that I had first heard in Little Rock and echoed in each of the other clinics and again in Charlotte “ I do not have health insurance, so I have no physician, and have no health care”.

Without access to care without ability to refill or pay for their prescriptions, again I saw patients with blood pressure out of control. Of the several dozen patients I personally cared for, the lowest diastolic pressure was 94. Most were above 100, some over 110. Diabetes was equally poorly controlled. The same was the situation for cholesterol. More than two thirds of the patients were obese but almost none had had seen a nutritionist.

As mentioned, Charlotte was the seventh free clinic where I had precipitated, so none of these clinical observations were surprising. What was surprising, was that there was such similarity of the stories of patients in each of these seven cities.

Reflecting on the entirety of my experiences, the Americans, most who never had previously sought free services of any sort, but now overcame their personal pride, signed up for appointment at these free clinics and then waited on line for many hours to be seen, reminded me of the long lines of people waiting on the bread lines of the great depression.

Then food was the essential. In the 1930’s medicine was something not expected by the lower and middle class and for those who did have access to care, the care they received was limited and of minimal benefit. There were no antibiotics, no intensive care, insulin had just become available for a few. The people waiting on the lines on the 1930’s did not consider health care something the government would or should provide for them. However, they did look to the government and charities to provide food.

Today, food is readily available and most people can afford to purchase, or are eligible to receive government subsidies for adequate food. In the eighty years since the bread lines, medicine has become something not recognizable by those who waited in the cold. Medical care has also become much more accessible - if one has health insurance or personal wealth.

However, the over 50,000,000 Americans who do not have health insurance they are unable avoid the complications of their chronic illnesses because they cannot benefit from the tremendous advances in medicine over the past eight decades. Without access to medical care of the twenty first century, the health of status of those we have seen at these free clinics, is not too different than the health status of the thousands of Americans who stood on the food lines.

Then many people relied on charity to put food in their stomach and food on their kitchen tables for their family. Today many people must rely on charity for medical care. Is there really much difference? Both are essential. In each instance, very large proportions of our citizens have become marginalized and their lives vulnerable.

Hi Dr, my name is Timi Olufemi we met at Washington DC during the free

health clinic. Yes , u were right I had yellow fever and malaria,

spent two days in the ICU and seven days total and one whole month of

recovery. Feel much better , thank you very much : God bless you.

email received 10/7/10 RBF

Hi Dr, my name is Timi Olufemi we met at Washington DC during the free

health clinic. Yes , u were right I had yellow fever and malaria,

spent two days in the ICU and seven days total and one whole month of

recovery. Feel much better , thank you very much : God bless you.

email received 10/7/10 RBF

Living in New Orleans without Health Insurance

Free Medical Clinic Ernest Morial Convention Center

August 31/September1 2010

It was the palpable ghosts of Katrina that made the free medical clinic that occurred in New Orleans for two days on August 31 and September 1, 2010 different than the five previous ones that I had been a volunteer physician. Most of the patients acknowledged these forces when they dated the onset, or worsening, of their medical problems to the hurricane of 2005. Because the clinic was for people who did not have any health insurance, many had not seen physician for two or three years. The absence of insurance precluded them from medical care and allowed the ghosts to hold these people hostage.

The emotional trauma experienced by so many of New Orlenans over the past five years and the many promises for aid that did not materialize made them doubt the clinic, organized by the National Association of Free Clinics (NAFC) and sponsored by donations solicited by Keith Olbermann on Countdown, would show.

As in New Orleans (2009 - 675 patients), Little Rock (992 patients), Kansas City (2110 patients in two days), Hartford (1028 patients), Atlanta (1310 patients), and Washington, DC (1378 patients), the clinic opened on time and cared for all of those people who had signed up before and those who arrived unscheduled. The first day the first patient was seen at 11AM and the last seen 10PM. The following day, the clinic started at 2PM and finished at about 9:30PM. Each day, the clinic provided care for about 675 patients. In the middle of the second day the 10,000th patient cared for by these mega-clinics was seen.

Perhaps half of the people who attended the clinic were working. The self-employed could not afford insurance. Some worked where health insurance was not offered for the employees, or they were not given enough hours on the job to qualify for insurance benefits. Some had recently lost their job but COBRA was too expensive so they let their coverage drop. There was the engineer from NASA, teachers with graduate degrees, a scientist who had been studying the effects of the BP oil spill, a worker who had been cleaning up the oil spill but recently laid off, the hair dresser who lost her job with Katrina and had returned to New Orleans but could not find a job, the construction worker and the truck driver. No class of people was spared. All went to sleep hoping that they would wake in the same state of health because they knew that id they became ill, they could not afford to see a physician. A hospitalization would bankrupt them.

New Orleans was the sixth clinic where I took time from my private practice and traveled to volunteer as a physician. My affiliation with the NAFC is a personal pledge. Having believed that health care is a right of all American citizens from the day I decided to go to medical school, after participating in my first free clinic last November in Little Rock clinic, where I saw the burden of disease experienced by fellow Americans living without health insurance, I committed myself to participate in all future clinics.

The care provided in New Orleans, as at the previous clinics, was not only to see a physician but also to have blood tests for diabetes, cholesterol, anemia, urinary problems Patients could be screened HIV. Electrocardiograms, gynecological exams, visual acuity, mental health counseling, as well as referrals for mammograms and colonoscopies were available as needed. If indicated, prescriptions were written from a formulary provided by Wal-Mart for either a 30-day supply for $5, or 90 days for $10. As in the other cities, the NAFC had extensively researched the free medical services available in the metropolitan area. Before discharge from the clinic, each person received referral to free health care in his or her neighborhood. Appointments were made for the patient and the record generated from their visit was sent where the patient could receive ongoing care.

The patients in New Orleans had the same spectrum of illnesses seen in the other clinics. The same illnesses I see in my private practice. It was not the illnesses that differ. It is the severity of the illnesses that is shocking. In my office in suburban Boston, I have patients whose blood pressure is in the 160-170/88-98 ranges with a rare patient having pressures higher. In New Orleans, as in the previous clinics, the patients had pressures are in the 180-210/96-120 range with an occasional patient having even higher numbers. The same was true for diabetes and cholesterol. Again obesity was epidemic. It would not be an exaggeration to say that seventy-five percent of patients were not only overweight but also obese.

Again the patients had the same comment I first heard in Little Rock and all the other clinics, “I don’t have insurance, I don’t have a doctor, and I don’t have medical care”. The stories from New Orleans were similar to all the other cities. It was not geography that made the story. It was the hardship of living in America without health insurance that made the story. One patient who had glaucoma, whose prescription had run out about two years before, was using his cousin’s eye drops. The vial of drops he brought with him had expired in 2005 and was for allergies not glaucoma. A fifty eight year old woman, had diabetes and a previous stroke. She was using her husband’s diabetic medications and had not had any blood tests for over a year managing her sugars as she had when she had insurance but without the results of blood sugars to make changes in her medications. She was also taking a medication to thin her blood as a prevention against another stroke but had not had the level of her blood thinner checked in the two years since she had lost her insurance.

As before, patients brought their bottles of medication. They were almost always empty. Most could not afford to see a physician to have them refilled. If they did have the prescription refilled, the cost of the medication made it very difficult to continue on the medication. What I did notice in New Orleans, more so than in previous clinics, was that the medications patients had been prescribed in the past were frequently were some of the most expensive medications. I may have seen a hand full of generic prescriptions, but most were for the newest and pricier drugs.

Because of the prevalence of obesity, gastro-esophageal reflux disease was also very common. Patients with this problem again had the most expensive medications. Most of them had never been treated with less expensive acid suppressing medication. Of those I saw, none had been counseled about eating behaviors and diet that provoke the symptoms of heartburn and reflux.

As in the previous clinics, there were hands full of t patients who had life threatening problems and had to be transported by ambulance to the closest emergency room. I sent a 64-year-old obese woman to the emergency with symptoms of acute pulmonary edema and accelerated coronary artery disease. She had not seen a physician since the symptoms began six months ago nor did she understand the significance of the worsening of the shortness of breath she felt every time she lay down or the chest discomfort brought on with three or four steps that had been accelerating in the past week. She was one of the several dozen people these clinics had cared for who very likely would not have seen the next day if it had not been for the care provided in these clinics.

I saw patients for about 10 hours the first day in New Orleans and eight hours the second day. In Washington, DC, I worked for almost 12 hours with one short break. So did many of the other professional and non-professional volunteers. Being able to help people who had been excluded from health care for many years was rewarding. However, as a physician who has been practicing medicine for almost forty years, it was uncomfortable to be a member of a profession that has failed to care for the millions of people who work hard, contribute to the economy, but cannot afford to access medical care.

What is particularly distressing, is that while the these clinics serve a fraction of the millions of Americans without health insurance, there are many groups around the country that are actively working to reverse the health reforms that Congress passed earlier this year. Some claim the reforms are too expensive, but do not take into account that they are already paying for the care of the uninsured when they arrive in the emergency rooms with critical illnesses that more than likely could have been cared for at a fraction of the cost in a doctor’s office. Even this does not take include the loss of productivity the person were he or she healthy enough to work.

I find it difficult to understand why the medical schools in the cities where the NAFC has had their clinics, have minimal presence. Despite many personal invitations, these schools that are preparing the physicians of the future have only provided one or two junior faculty and two or three medical school students.

Even with so many citizens who have no health insurance, only one member of Congress has attended and none have participated.

Where are they?

Some politicians scare people by calling the recent health reforms death panels and get a stream of press coverage. But no one speaks of the death panels that exist in the lines of people in need of care lining up and waiting hours to be seen at a free clinic. It is the millions of people, who with the new reforms, will be able to receive coverage and access to care that are, and should be, the focus of reform. Estimating the cost of these reforms cannot be done without taking into account the monies already spent on their care.

As the mid-term elections approach, Americans who have health insurance should hear the story of those citizens who live in America without health insurance. Those who argue against it should visit and spend a day talking to the people attend these clinic so they can better understand the consequences of not providing health care for every one.

The most poignant story from all of these clinics was from a woman who volunteered to escort patients from one station to another at the clinic in Kansas City. At the end of the clinic, she came over to the woman who directs these clinics and gave her a long and emotional hug with the remark, “thank you for letting me volunteer for this event. I did not know that the person I was wheeling through the clinic was my neighbor.”

New Orleans Free Clinic

/Users/Ralph/Desktop/NAFC - New Orleans.doc

Free Health Clinic Comes To DC Aug. 4

Free Health Clinic Comes To DC Aug. 4

The Nation's Biggest Free Clinic | Parade.com http://www.parade.com/health/2010/05/09-... Across America volunteers are helping the uninsured

Free Health Clinics Benefit Volunteers and the Uninsured- AARP

Free Health Clinics Benefit Volunteers and the Uninsured- AARP

Atlantic Free Clinic

http://www.parade.com/health/2010/05/09-nations-biggest-free-clinic.html

Let’s get one thing straight. Americans want health reform. Those who say otherwise should look in the mirror to check their noses. The uninsured do not have the time or the means to make their case to Congress. It is Congress’s responsibility to reach the almost twenty percent of their citizens who awaken every day praying that no one in their family is ill because they have no insurance and thus have no access to care and cannot get treatment.

Those congressmen who plead they must vote for what is best for their constituents do not know their constituents because the ‘plague’ of the uninsured is endemic to every corner of our county. They may know those who give financial support but they are elected to advocate for all of their constituents. They also are members of the Congress of the United States and have responsibility to do what is best for all Americans.

So let’s be honest. If you can sleep soundly at night knowing by morning twenty percent of your neighbors may have to choose the health of themselves and their family or putting food on the table and keeping a roof over their heads, then vote against the bill. But do NOT be the coward who says that ‘my constituents don’t want it’. Say that those corporations that gave me money for my campaign don’t want it.

R Freidin, MD

It's a Right..........not a Priviledge

It’s a Right……………..not a privilege

Yesterday, between patients, I watched the president’s health summit. When Senator Clyburn state that health care is a right, I was reminded of a presentation I was asked by the St Louis medical society about a small health center that a few of my classmates and I had organized in the Pruitt-Igoe projects. Explaining why we had decided to divert our attention from the library and anatomy lab, I said, “ Health care is a right - not a privilege.

As an pre-med student, studying American history, I fantasized that if our Constitution had been written in mid twentieth century the unalienable Rights “Life, Liberty and the pursuit of Happiness”, promised to ‘all men’ would have meant equal access to health care. I had no idea that claiming that health care, as a right of all citizens would be so controversial.

I can still feel the stirrings and hear the whispers of shock. My intent was not to be provocative. It was what I believed. It was confirmed in the first weeks of my freshman year as I walked to class past rows of long benches of people waiting in the clinic for free care and saw the same people still waiting as I returned from class.

That was 1966. Now more than 40 years later, our country remains divided by those who believe that health is a right and those who believe it should be purchased in the ‘market place’. This was what I took away from the president’s forum.

It was not Republican versus Democrat. It was those who believed that everyone should have access to basic health care and those who believed that health care is a commodity traded in the market place and available to those who can afford to pay. For all citizens to have access, the federal government must be involved as it is for other programs that are made available to everyone. On the other hand, if health care is traded in the market, it should remain in the private sector.

That is the divide. After listening to yesterday’s discussion, this is a bridge too far. One of the unspoken items of the forum was that health care has been in the market place. The market has produced a health system that everyone agrees requires reform. So why would anyone trust the market forces to realign itself to now allow those who have until now been denied or unable to afford access ‘into’ the system? This is was what was the unspoken message from the Blair House.

The problem is that in the past four decades, the ‘market’ has proven itself unable to meet this challenge. Now it is the time to for a new tact an allow government regulation, incentive, and guidelines a chance to create the mechanisms to assure that all Americans can pursue ‘twenty first century happiness’ and benefit from the advances in modern medicine that until now has been only available to those who have been fortunate to be have been blessed by the market.

Ralph B Freidin, MD

http://theunseenpatient.blogspot.com

Lexington, MA

.

HELPING

Haiti - What a tragedy. How long will it take to create order out of this disorder? Perhaps 10 -20 years will come and go before we can say job done, and it may be fifty or more before we can think of saying ‘job well done’

It is inspiring to see and hear of the thousands who have left home and jobs to help the victims of this catastrophe. But it puzzles me how quickly suffering beyond our borders is seen while the suffering in front of our noses is rarely seen.

Clearly it is not a reluctance to assist others distant form us. Witness Haiti and the tsunami of 2004. However, we seem reluctant to assist those close to us. Is it because we cannot acknowledge that suffering of similar magnitude occurs within our borders? To do so, we would have to accept that there are two Americas. With just less than twenty percent of our citizens unable to afford health insurance, if we are honest with ourselves, this dichotomy is not deniable.

Having personally seen how ‘my neighbors’ live without health insurance in Arkansas, Missouri, and Connecticut, and having heard how they get by in Texas and Louisiana, I know that there is much suffering here in our country and it is not limited to one area. It is everywhere one cares to look.

As a physician for more than forty years, when I think about those of us who live without the security of health insurance, it is clear that our current system of health care, dominated by private insurance, has deprived them of many of the advances of current medical practice. Could there be a better reason for reform?

There are several ways of responding to this home-grown crisis. One is working at a free clinic (www.freeclinics.us). One can also speak to his/her congress person. If we all call our representatives on February 24^th during the president’s health summit, we be assisting those American citizens who need as much help as the refugees of the Haitian earth quake or the Indian Ocean tsunami.

Ralph B.Freidin,MD Boston,MA

_{CONGRESS BICKERS - SUFFERING CONTINUES}

_{They arrived early at the Connecticut Convention Center as they had before in Little Rock and Kansas City. The line formed long before the doors opened. As a primary care doctor, I had come to help the National Association of Free Clinics run a one-day medical clinic in Hartford, CT to provide care for anyone without health insurance. This was the third time I was volunteering for a one day free clinic}

_{Volunteers, health professionals came from around the country to participate.}

_{I came from Boston where I have practiced primary care medicine for thirty-three years. I was asked to triage the registration line for anyone needing urgent care. As the line grew, I made my way through the crowd.}

_{Most were working. Others had been laid off. None had health insurance. Half had not seen a doctor since 2000. A third did not go anywhere. They did not have insurance. They did not have cash. Those who had been to the doctor could not afford to fill their prescriptions.}

_{A man, with a below knee amputation, rested in his wheel chair.}

_{His medical insurance had denied his prosthesis. He hoped the clinic could assist him in obtaining a prosthetic leg so he could return to work and care for his family.}

_{A woman, grimacing in pain, had cancer treatment two years ago, but without insurance she was unable to continue treatment. No insurance, no physician, no medication.}

_{Another woman wore a trench coat to cover her emaciated frame. She had had three seizures in the past two weeks. A local emergency room told her that the level of her seizure medications was “OK” and discharged her. No follow up was arranged. During her seizures she had bitten the inside of her mouth that she now could barely open. I could not see an intact tooth in her smile. She could not eat. No Insurance, no doctor, no care.}

_{A young man with labored breathing and sweaty brow was given a wheelchair. His weak voice told me five days ago he was in the intensive care unit of a local hospital for leg swelling. He did not understand why his legs had swelled then nor why the swelling had recurred. For a month, he experienced chest pains walking across his living-room. He needed three pillows to avoid awakening from sleep breathless. At discharge, he was handed a list of unaffordable medications that he did not understand. Continuing care was not arranged.}

_{HHe had an unstable heart condition. I wheeled him to the front of the line. An ambulance was called. He was taken back to the emergency room with a possible heart attack. Why was this man’s leg swelling and chest pains not completely evaluated before discharge? Was it because he did not have health insurance? Had there been no free clinic, and his daughter not insisted that he come, he may have died. No insurance, no physician, no continuity.}

_{A young man tried to avoid eye contact. His slouched posture told me he did not want to talk, but had something to say. Later, I learned the suicidal plans of three young people had been averted. Surely he was one. Would they have completed their plans were it not for the free clinic? No insurance, no access, no help.}

_{A woman was leaning against the wall breathless. She was taken out of the line and seen immediately and then transported to the closest emergency room for acute congestive heart failure. No insurance, no doctor, no care.}

_{Diabetes was her problem said a middle aged woman who had not seen a physician for three years. I asked her who was helping her control her diabetes. “Oh, I do” she said. “But where do you get the medicine” I asked. Staring me straight into my eyes she replied unabashedly “I get it from my brother who gets it from his doctor”. No insurance, no doctor, no medication.}

_{Over one thousand patients were seen at each of these one day clinics. More were turned away. From the south through the mid west and into the northeast, all the patients, as if rehearsed, said the same thing: “No insurance, no doctor, no care”.}

_{The day was overwhelming. In each city, I felt I was in a undeveloped country. I had seen patients with this burden of illness, but that was 40 years ago in medical school.}

_{The American Medical Association claims to support health reform, but they were not in Little Rock, Kansas City, or Hartford. Absent was the American Association of Medical Schools planning the education of tomorrow’s physicians remote from the health crisis of today. My profession shames me.}

_{Despite multiple invitations, absent were the politicians, bragging with self-righteousness, that they cannot support a ‘public option’ all giving a multitude of reasons filled with hypocrisies and fictions.}

_{The cost of reform is not the question. We already incur the expense with the loss of manpower and the extraordinary cost emergency, and end of life care. The question is how much it costs not to reform. The question is how much we value our neighbor and fellow citizens. The question is how long our nation will allow the million citizens without health insurance to remain unseen. The question is of how we see ourselves.}

_{No self-respecting, informed person could honestly believe without a public option private insurance companies will write policies to alleviate the suffering I witnessed in Little Rock ARK;, Kansas City,MO: and Hartford,CT. The opportunity was theirs for more than fifty years. They did nothing. It is time for reform.}

_{Ralph B Freidin, MD}

_{Boston, MA}

We Already Have Death Panels

Death panels do exist in American health care, but they are not your grand mother's death panels. Rather they are for those citizens who live without health insurance in our immensely wealthy, but morally wanting,country.

For those of us who cannot afford, or whose job does not provide health insurance, death comes sooner and with more pain.

As a physician, I have witnessed this when I volunteered at the free one-day medical clinics in New Orleans,LA; Little Rock, ARK; and Hartford, CT; and the two-day free clinic in Kansas City, MO. These events were organized by the National Association of Free Clinics and sponsored by funds raised by MSNBC. Each day, we provided medical, mental health and some dental care more than 1000 patients.

There I saw working Americans with untreated hypertension, uncontrolled diabetes, undiagnosed heart disease, crippling arthritis and rotting teeth. We saw patients with impending heart attacks and desperate people with clear suicidal plans.

Yes, Congress, there are death panels. By not including all of our citizens, our system of health care has death panels for the one sixth of our citizens who do not have health insurance. Your job is to pass heath reform and kill these panels, and not our neighbors.

Ralph Freidin, MD

Lexington, Mass.

TESTIMONY OF ONE OF THE MANY PATIENTS CARED FOR AT

THE HARTFORD FREE CLINIC FEB 3 2010

"Hello Nicole. My name is Carol Wichen and I was a patient at the Hartford Clinic on February 3rd. A very short time after arriving I was rushed to the hospital I was in hypertensive crisis and congestive heart failure. I called to thank you guys for being there and also to thank the gentleman- I think he was a doctor -who noticed I was in distress. The prompt care is why I am here today, I got out of the hospital yesterday. I was there in the knick of time, I was there for one week. And I just wanted to thank you guys for being there for us who don't have anyone or anything. God bless you all. You saved my life you are my team of angles."

If it were not for these free clinics who knows what would have happened to this woman and the countless others that we have yet to hear from. Is there any doubt that health reform is necessary.

Ralph Freidin

Lexington Minuteman Feb 4, 2010

Freidin: Suffering continues while reform in D.C. collapses

By Ralph B Freidin, MD

GateHouse News Service

Posted Feb 05, 2010 @ 08:42 AM

Lexington —

The line formed long before the doors opened. As a primary care doctor, I had come to help the National Association of Free Clinics run a two-day medical clinic in Kansas City, MO. Previously, they had had clinics in New Orleans, La. and Little Rock, Ark. All were organized to provide free services to anyone without health insurance.

Volunteers and health professionals came from around the country.

I came from Boston where I have practiced primary care medicine for 33 years. I was asked to triage the registration line for anyone needing urgent care. As the line grew, I made my way through the crowd.

Most were working. Others had been laid off. None had health insurance. Half had not seen a doctor since 2000. A third did not go anywhere. They did not have insurance or cash. Those who had seen a doctor could not fill their prescriptions.

A man with a below knee amputation rested in his wheel chair. His medical insurance had denied his prosthesis. He hoped the clinic could assist him in obtaining a prosthetic leg so he could return to work and care for his family.

A woman grimacing in pain. She had cancer treatment two years ago but without insurance, she was unable to continue treatment. No insurance, no physician, no medication.

A trench coat covered the emaciated frame of another woman. She had had three seizures in the past two weeks. A local emergency room told her that the level of her seizure medications was “OK” and discharged her. No follow up was arranged. During her seizures she had bitten the inside of her mouth. She could barely open it. There was not an intact tooth in her smile. She could not eat.

A young man with labored breathing was given a wheelchair. His weak voice told me five days ago he had been in the intensive care unit of a local hospital for leg swelling. He did not understand why his legs had swelled then or why the swelling had recurred. For a month, he experienced chest pains walking across his living room. He needed three pillows to avoid awakening from sleep breathless. At discharge, he was handed a list of unaffordable medications that he did not understand. Continuing care was not arranged.

He had an unstable heart condition. I wheeled him to the front of the line. An ambulance was called. He was taken back to the emergency room with a possible heart attack. Why was this man’s leg swelling and chest pains not completely evaluated before discharge? Was it because he did not have health insurance? Had there been no free clinic, and his daughter not insisted that he come, he may have died.

A young man avoided eye contact. His slouched posture told me he did not want to talk, but had something to say. Later, I learned the suicidal plans of three people had been averted. Surely he was one. Without a free clinic, would their plans have succeeded?

The day was overwhelming. I knew that I was in Little Rock, but it felt like I was in a remote undeveloped country. I had seen patients with this burden of illness, but that was 40 years ago in medical school.

The American Medical Association claims to support health reform, but they were not in Little Rock. Absent was the American Association of Medical Schools planning the education of tomorrow’s physicians remote from the health crisis of today. My profession shames me.

Absent were the politicians, bragging with self-righteousness, that they cannot support a “public option” giving a multitude of reasons filled with hypocrisies and fictions.

The cost of reform is not the question. We already incur the expense with the loss of manpower and the extraordinary cost of end of life care. The question is how much it costs not to reform. How much do we value our neighbor? How long will our nation allow 43 million citizens to be marginalized without access to medical care?

No informed person could honestly believe that without a public option private insurers will write policies to alleviate the suffering I witnessed in Little Rock. My country embarrasses me.

We squabble over health reform and across the country patients suffer and die daily without proper care. Doing nothing cannot be an option.

Ralph B Freidin, MD lives in Boston but has a practice on Bedford Street in Lexington.

Copyright 2010 Lexington Minuteman. Some rights reserved

Keep it simple

Passage of health care reform is a must. I have long believed health care to be a right for all American citizens. Equality thus is the basis for my commitment to reform.

However, reforming our system is perhaps the most condenses of any social policy our country has faced in the past half century -perhaps even longer. The reasons are many. Foremost is that we have permitted, and encouraged, health care to be a commodity unlike other countries in the western world where it is a public service.

The passage of Medicare and Medicaid was a triumph of an idea that had been proposed decades before going back to Teddy Roosevelt, Franklin Roosevelt, Harry Truman and then Lyndon Johnson.

When I first considered medicine as a profession was during the debates over Medicare. I had previously spent time in England and learned about their National Health Program. Socially minded, I was shocked at the resistance solicited from the distortions promulgated by the AMA, pharmaceuticals, and social conservatives. Having the government involved in health care would be an irreversible step toward Communism, the quality of care would be compromised, and the care would be rationed. The same falsehoods were shouted at town meetings this summer and continued into the recent senatorial election in Massachusetts.

Now asking anyone to give up his or her Medicare card is like asking a strange dog to give up his bone

Why were the Democrats successful in 1965 but failed in 1993 and now are balancing on the brink of failure in 2010? Again there are many. Social changes then were to include; now they seem to be to exclude.

Then the AMA was a more powerful organization, but insurance companies were not. HMO, PPO, or doughnut did not exit. Following the defeat of President Clinton’s health bill, further solidified those interests entrenched in selling the commodity of health.

Today these same interests are feeling even more emboldened and confident of an unencumbered future if the current reform is watered down or defeated.

So what to do? Take a lesion from the one president who succeeded.

Tell the stories of people excluded from the health system. Tell people what the program will do for them as they enter their doctor’s office, the hospital, or the pharmacy. Tell the people that the principle underscoring health reform is the same as that upon which our nation was established - equality. Tell the people how easily it is to go from having health insurance to joining the one sixth of Americans without insurance. After telling these stories, tell them again!

To do this we must meet with our representatives in congress and insist they do what they were elected for. We must speak to the press to tell the truth about health reform. Tell the story of the influence that the insurance companies, pharmaceutical companies and medical equipment companies have in DC.

When talking about cost, do it in numbers that the public can comprehend. Better than that would be to tell it in the out of pocket costs to the individual. Tell it by comparing how much he or she, is currently paying for the care provided the uninsured and underinsured and over insured and compare it to what one may have to pay with this bill

Explain that social change impacting every citizen is bound to be messy. But don’t talk of the deal to pay for a state’s Medicaid bill without talking of the deals made by the insurance companies and pharmaceuticals and professional organizations. At least those monies for Medicaid will go to people who are desperate rather than into the over-stuffed pockets of management

Keep It simple - no insurance, no doctor; no doctor, no access; no access no treament. But do it.

The Need for Health Reform - Root Causes

Although the chances for passage of a health reform bill have diminished with Scott Brown’s election to the senate, the need for reform is unchanged. Fifty seven million American citizens awake each morning praying that they and their family avoid illness because they do not have health insurance and have no way to pay for it. They know the catastrophe that will befall them if they are injured on the job or have to seek medical care.

There are three major reasons for this dilemma and why health care in America is needed: the conflict of interest in health insurance; the pricing of medicine; and the inverted scheme of physician reimbursement.

Health Insurance

It will not possible to control the cost of health care until private insurance companies are controlled. They promote themselves as servicing their customers while disguising their primary allegiance to their Wall Street investors.

Private insurance companies, by definition, have a conflict of interest. Until it is unchallenged, cost containment will be an illusion. The explanation is simple. Private insurers pay out 75 to 80 cents on the dollar while Medicare pays out

95 -97 cents on the dollar to their respective subscribers. Private insurance companies provide 'care' to a pool of healthier and younger subscribers with a 20-25% overhead while Medicare provides care to older patients with more illness with an overhead of less than 5%. No other business could remain solvent if they opted for a 75-cent return in place of 95-cent return on each dollar invested.

The objective of private insurers is making money for Wall Street and their investors from the sale of health insurance policies. If their objective is to maximize profits for Wall Street, they must compromise their payment for service to their subscribers. They face a conflict of interest every time they decide if a claim will be covered. To continue to attract investors their priority must be their fiduciary responsibility. Payments for claims become a direct conflict to this goal - more payments to patients are fewer dividends to investors.

If too many payments are made, there will be less to return to investors. Wall Street will look upon them less favorably and fewer people will invest. Increasing the price of premiums compensate for these losses.

A graduate degree in economics is not required to understand this. Simply stated - if you owe Joe ten dollars and Jane ten dollars but only have twelve dollars in your pocket, you can only pay one in full.

.

As a primary care physician practicing for 35 years, I have never had Medicare, Medicaid, the Veterans' Administration or any other government organization contradicts my medical decisions, ask me to prescribe this medicine rather than that, or order this test and not that. However, private insurances daily question my judgment. Although the insurers claim these oversights are necessary to control costs, I don’t see patients receive more services. What I do see is regular increases in premiums.

Recently, a patient came to see me with the worst headache he had ever experienced. After obtaining a detailed history and performing a careful general and neurological exam, my primary concern was a cerebral hemorrhage. I asked my secretary to arrange for an emergency MRI scan to be done later that day and had the patient wait until we had a definite time. Fifteen minutes later my secretary interrupted me saying the scan required prior approval and was not sure how long that would take.

Immediately, I called the insurance company. A young voice came answered and began to ask me a series of questions. Had I had examined the patient? Had I taken the patient's blood pressure? I said that I had and that the first concern in my differential diagnosis was a cerebral hemorrhage and that the patients’ headache was the initial symptoms. She paused but still would not authorize.

I then said should the patient suffer the consequences of a cerebral bleed, I would hold her and the insurance company responsible. She transferred my call to the physician reviewer. After asking many of the questions I had already answered, he authorized the scan.

How much of my time did this take? How much risk to the patient was incurred by the delay? How long did my other patients have to wait? I don't know. But I do know that stories like this occur weekly. Less dramatic stories occur daily. The federal government does not control our health system, Wall Street does.

DrF Jan 25, 2010

Cost of Medicine and Physician Re-imbursements to follow later this week.

January 15, 2010

I received email notification that JAMA rejected my 'Piece of Mind' essay. It was a terse we are not interested. No mention was made of the content, their objections, or the quality of writing. This makes the third rejection of what I thought was a solid piece of writing about a major gap in the health reform conversation - the burden of illness carried by hard working US citizens who live without health insurance. I believe giving access to care to these millions is the most important feature of the current health bills. There have been statistics of this group and how much providing access may cost, but there has not been enough personal stories. These stories cut through so much of the resistance to reform because they tell real stories of real people with poor health, at high risk for worse health because they cannot afford American health care, who wake up every day hoping that they do not become ill or hurt.

Having been a member of the medical profession for 40 years and practiced general internal medicine for more than 35 years, I have seen both the amazing medical advances of the past four decades as well as the failings of the way we provide care. My experience is not unique. What perhaps is unique is my determination to tell my professional story. If the newspapers and the medical journal don't want to publish it, starting today I will try to tell it on my blog. DrF

Living in America Without Health Insurance

LIVING IN AMERICA WITHOUT HEALTH INSURANCE:

THE CLINIC

The line formed long before the doors opened to the Convention Center in Kansas City, Missouri. This was the third free medical clinic arranged by the National Association of Free Clinics. Previously, they had had clinics in New Orleans and Little Rock. All were organized to provide free services for anyone without health insurance and to arrange for continuing care through the resources in their local community.

Services were provided by hundreds of volunteer health professionals. There were thousands of concerned citizens who also gave their time. Many came long distances. I traveled from Boston to Kansas City for the two-day clinic. Four weeks before I had been in Little Rock, Arkansas for a one-day clinic.

My job was to triage the registration line for anyone in need of urgent care. This allowed me to walk through the crowd and hear the stories of tens of citizens while they patiently waited to be seen. I thought my thirty three years of practicing primary care medicine in municipal hospitals and the community would have prepared me for what I was about to see. It did not.

THE PEOPLE

More than 80% of those who came for care had jobs - one and sometimes two and three - but their employers did not offer insurance. Others did not work enough hours to qualify for their employer’s health benefits. Some were self employed but could not afford premiums. Some had lost their jobs. Some were looking for work. None had medical or dental insurance.

More than 60% of them had not seen a physician in the past year, and 48% had not seen a doctor since 2000. A third did not go anywhere. If they had seen a physician, they could not afford to fill their prescription. The charges they had incurred in one visit intimidated them from returning. Any care they may have received was fragmented and without follow up.

All had the same reasons for neglecting their health. Without insurance, they could not afford to pay for a physician visit. Without insurance they could not afford to fill their prescriptions. Without insurance, they could not afford any surgical procedure. If they had been sick enough to need emergency care, they were then saddled with an enormous bill that intimidated them from seeking further care of any sort.

THEIR STORIES

A man, who had had a below knee amputation, sat awkwardly in his wheel chair. Having lost his insurance, he hoped the clinic would assist him obtain the prosthesis his medical insurance had denied devastating his hopes to walk again, return to his job and to provide for his family. No insurance, no physician, no prosthetic leg.

A woman grimacing in pain had cancer treatment two years ago but was unable to continue treatment. No insurance, no physician, no medication.

Another woman wore a trench coat to cover her emaciated frame. Her seizures had recurred three times in the past two weeks. She had sought help in an emergency room only to be told that the level of her seizure medications was “OK” and then was discharged. No follow up was arranged. During her seizures she had bitten the inside of her mouth and broke several carious teeth. She could not eat. No insurance, no physician, no follow up care.

A young man with labored breathing had been given a wheelchair. Struggling to speak, he told me five days ago he had been treated in the intensive care unit of a local hospital for “leg swelling”. He did not understand why his legs had swelled then or why the swelling had recurred. For a month, he experienced chest pains walking across his living room. He needed three pillows to avoid awakening from sleep breathless. At discharge, he was handed a list of unaffordable medications that he did not understand. Continuing care was not arranged.

He was immediately pulled aside, examined, an EKG was taken, and an ambulance was called to take him back to the emergency room with an acute coronary syndrome. Why was this man’s leg swelling and chest pains incompletely evaluated before discharge? Was it because he did not have health insurance? Had there been no free clinic, and his daughter not insisted that he come, he may have died. No insurance, no physician, incomplete hospital care.

A young man avoided eye contact. His slouched posture told me he did not want to talk, but had something to say. Later, I learned the suicidal plans of three people had been averted. Surely he was one. Without a free clinic, would their plans have succeeded? No insurance, no physician, no treatment.

By the end of the two days, we had cared for 2434 people. I was overwhelmed. It was not the number of patients. It was not their illnesses. They had the same diagnoses one would expect among any group of young and middle-aged adults - hypertension, diabetes, emphysema, degenerative arthritis, coronary heart disease, chronic pain, carious teeth, as well as depression.

It was the severity of their illnesses: untreated diabetes with hemoglobin A-1-C of 12.6 because the person had run out of medications months ago; blood pressures of 190/120 that had never been diagnosed; advanced osteoarthritis with crippling pain but never treated with more than over the counter medications. No insurance, no physician, no operation.

Every patient’s story ended with the same refrain: “ No insurance, no physician, no access to care.” It was spoken in hypertension, diabetes, heart disease, depression, and every other diagnosis.

COMMENT

Could I really be in America? It certainly did not feel that way, at least not America of the 21st century. I had not seen patients with this burden of illness, since my first year in medical school 45 years ago - before Medicare was fully implemented. Viewing the rows of patients filling the Kansas Convention Center, I again felt as ashamed by the failings of our medical system of 2010 as I had as a medical student by the system of American health care of 1965 walking by the rows of patients waiting to be seen in the hospital’s outpatient department.

Without health insurance, these hard working, tax paying citizens from New Orleans, Little Rock, and Kansas City, have been denied the benefits of the medical advances of the last four decades. I am sure there are others just like them in every community of America.

The American Medical Association claims to support health reform, but they were not in Little Rock. Absent was the American Association of Medical Schools planning the education of tomorrow’s physicians but remote from the health crisis of today.

There were no deans of medical schools or officials from the American College of Physicians or Pediatrics. Could there be a more important mission for professional societies or medical schools than assuring all citizens have access to basic medical care. My profession shames me.

Absent were the politicians, bragging with self-righteousness, that they cannot support a ‘public option’ citing a multitude of hypocrisies and fictions. They pretend to reform our health system without reforming health insurers. How can a country so materially rich be so morally bankrupt?

The cost of reform is not the question. We already incur the expense with the loss of manpower and the extraordinary cost of emergency and end of life care. The question is how much it costs not to reform. The question is how much do we value our neighbor? The question is how long will our nation allow 43 million citizens to be marginalized without health insurance?

We squabble over health reform and across the country patients suffer and die daily without proper care. No informed person can honestly believe that without strong intervention private insurers will write policies to alleviate the suffering I witnessed in Kansas City and Little Rock. My country embarrasses me.

Doing nothing cannot be an option. Ralph B Freidin, MD