Friday, January 29, 2010

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.

Monday, January 25, 2010

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.

Monday, January 18, 2010

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

Sunday, January 17, 2010

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



No Insurance, No Physician, No Medication

No insurance, No physician, No medication

They arrived early - before the doors opened. The National Association of Free Clinics had organized a one day medical clinic in Little Rock Arkansas provide free care to anyone without health insurance.

Volunteers, health professionals and others, came from around the country to provide their services.

I came from Boston where I have practiced primary care medicine for the past 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.

Many were working. Others had been laid off. None had health insurance. Five men had untreated blood pressures greater than160/100. Current practice treats pressures greater than 140/80. Two said they had not seen a doctor in two years and the others had never seen a doctor. Either they did not have cash or insurance. Those who had been to the doctor could not afford to fill their prescriptions.

A man with a below knee amputation was in a wheel chair. He hoped the clinic would assist him to obtain the prosthesis his medical insurance had denied devastating hopes to walk again and return to his job and be able to provide his family.

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

Another woman was wearing a trench coat to cover her emaciated frame. She had come without an appointment. Her concern was having three seizures in the past two weeks. A local emergency room where she had sought help told her that the level of her seizure medications was “OK” and then discharged her. No follow up was arranged. During her seizures she had bitten the inside of her mouth that she barely opened. I could not see an intact tooth in her smile. She could not eat.

A young man with labored breathing and sweaty brow was slumped in a wheelchair. His weak voice told me five days ago he was in the intensive care unit of a local hospital for swelling. He did not understand why his legs had swelled then or why the swelling recurred. For a month, he experienced chest pains walking across the 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 was 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. Because he did not have health insurance? Had the free clinic not occurred and his daughter not insisted that he come to the free clinic, he may have dropped dead!

A young man tried to avoid eye contact. His slouched posture said he did not want to talk, but had something to say. Afterwards, I learned the plans to commit suicide of three young people had been averted. Surely he was one. Would they have completed their plans were it not for the free clinic?

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’ for a multitude of hypocrisies and fictions, as they reform our health system without reforming health insurers.

The cost of reform is not the question. We already incur the expense with the loss of manpower. The question is how much it will cost not to reform. The question is equality. The question is how we value our neighbor. The question is how long our nation will allow 43 million citizens to be marginalized. The question is of how we see ourselves.

Can one honestly believe that without a public option private insurance companies will write policies to alleviate the suffering I witnessed in Little Rock.

Ralph B Freidin,MD

Lexington, MA

Triage Line - Little Rock, AK Free Clinic 11/21/09

click for video

Little Rock Free Clinic

Suffering in Silence in Little Rock

Saturday Novermber 21, 2009

They began to line up about 45 minutes before the doors to the one-day health clinic opened. The event, organized by the National Association of Free Clinics, was going to provide free medical care to anyone wanting to be seen as long as they did not have any health insurance.

Perhaps because I have had 40 years of experience practicing medicine, I was assigned to be the person to look for anyone in the line who needed urgent care. As the line grew I made my way through introducing myself and asking how we could help them today.

In the first hour of speaking to over a hundred people, (ten percent of all those seen) I saw five middle aged men with untreated hypertension all with diastolic pressures of over 100. Standard medical practice is to treat a diastolic pressure greater than the low 80’s. Two of these people had not seen a doctor in more than two years and the others had not seen a doctor at all. Either they did not have the cash or the insurance. The two who had been to the doctor were not taking medication because they could not afford it.

Sitting in a wheel chair in the midst of the crowd was a middle-aged man with below knee amputation who hoped that we would be able to help him obtain prosthesis. He had some medical insurance but it had just denied his request sinking his hopes to be able to walk again so that he could return to his job as plumber and support his family.

There was a woman who had cancer treatment two years ago but was unable to continue with her care again because she did not have insurance. But it was not her cancer that was her concern today of. Her face was grimacing with the pain of a terrible toothache that she had been suffering with for the past two weeks. Again - no insurance, no physician, no medication.

Then I spotted a woman off to the side of the line wearing a trench coat to cover her emaciated frame. She did not have an appointment but had had three grand mal seizures in the past two weeks. A week ago she had been seen in a local emergency room where she was told that anti seizure medications was “OK” and then discharged without arrangement for any follow up. In addition to her uncontrolled seizures, she had terrible dental pain such that she could not eat. I could only see the roots of her teeth. There was not an intact tooth visible.

Leaning on the railing was a woman panting after walking a half a block to get in line. She had no asthma medication and had not had any in more than six months. Behind her was a thirties year old man who had already been given a wheelchair because he was having difficulty breathing. In a soft voice he said that he had just been discharged from the intensive care unit of a local hospital where he had been treated for swollen ankles and shortness of breath. He was not sure what was wrong with him but for the past month he had been having chest pains every time he walked more than a few yards, he was sleeping propped up on pillows, and his ankles had begun to swell. When he was discharged he was given a list of medications that he could not afford, did not understand and arrangements for his continued care had not been made. About an hour after, I had brought this gentleman to the front of the line he was being attended by an ambulance crew on his way back to the emergency room with a possible heart attack.

Looking further down the line I saw a young man avoiding any eye contact. His slouched posture told me he did not want to talk but had something very heavy on his mind. Later I heard that there had been three young people who had plans for suicide that had been foiled. I was quiet sure that he was one of them.

I knew that I was in Little Rock, Arkansas because it was written on the school buses I had seen the day before parked outside of the Central High School and it was written on the front of the airport terminal. But I did not feel I was in America - at least not the America of the 21st century. Sure I had seen patients with these illnesses before but the last time was in my first year of medical school, which was the first year of Medicare.

What is it with my profession? What is it with those who set policy in an agriculturally rich but morally poor midwestern state? What is it with our county that gives so little value to the ‘small person’?

I feel as embarrassed by my profession as I did when I read the hysterical fear generating campaign to block the passage of Medicare in 1965. OK, this time the American Medical Association says that it supports health reform, but I did not see them in Little Rock at the free clinic. Nor were the politicians who brag that a ‘public option’ is something they cannot vote for because they must first think of what is in the best interest of the people of their state. When I juxtapose my experience in the Free Clinic to these self-righteous proclamations, I hear the clarion of hypocrisy. No self respecting educated person could possibly believe that without the impedance of a public option will a private insurance company will ever write policies to alleviate the amount of suffering of so many people I witnessed last Saturday in Little Rock.

It is not a question only how much reforming our healthcare will cost, it also is a question how much it will cost not to fix it. It is a question of equality, how we as a nation value our neighbor - how we see ourselves.

I am convinced that if the Declaration of Independence were written today ‘the pursuit of happiness’ would include access to basic health care.

Comment on Sen Harkin's opinion of Senate Health Reform bill

Huffington Post

Kansas City Free Clinic Video

click here for video

Highlights from my career in civil rights and primary health care

Ralph B. Freidin, MD

Pruit Igoe Neighborhood Health Center, St. Louis, MO (Founding Director ‘65-69)

U.S. Health Education Welfare Dept., National Center for Healthcare Research and Development (Developed first-ever primary care tracks for U.S. medical schools, ‘70-72)

Chief Medical Resident Boston City Hospital (‘74-75)

Director, BCH Primary Care Center ‘75-78)

Brigham and Women’s Hospital (‘78-80)

Clinical Faculty, Harvard Medical School (78-present)

Private Practice in Internal Medicine: Lexington, MA (‘80-present)

Clinical Instructor, Harvard Medical School and Tufts University School of Medicine:
"Doctor-Patient Relations: Introduction to Medical Interviewing for 1st Year Medical Students" (this course teaches young doctors to communicate effectively with diverse patients), (2006-2009)

Board of Governors, Human Rights Campaign (2005-present)

National Association of Free Clinics: Volunteer Physician, Little Rock, AK and Kansas City, MO (2009)

I have a 31 year-old daughter and a 29 year-old son and have been happily married for 41 years.