Health Care Meltdown

The UW FP Chair references Dr. Lebow...

2009-10-30T09:54:00.000-07:00

I'm at the Pacific Northwest Summit for Transforming Primary Care today. This is, as you know, a time of great energy and discussion about the state of medicine in the United States, and the role of primary care in the solution. And, it's a great discussion.

I was pleased to see, early in the day's discussion, a slide presented by Dr. Jim Davis, the chair of the Department of Family Practice at University of Washington which used as a reference the Healthcare Meltdown, by Dr. Jim Lebow!

It was great to see this, since I find so much encouragement from Dr. Lebow and the testimony of his life's work.

"Delayed Care: Rationing American Style"

2009-09-20T12:26:00.001-07:00

There are those of us who have worked toward justice in our healthcare system for years; even when I was a physician-owner of a for-profit medical practice, I was resistant to actions which were inherently unjust toward those in need. So, for many of us, the healthcare reform debate has been a long time coming.

And, I'm still caught off guard that this issue has indeed become so commonplace. I was at a coffee shop the other morning for breakfast with my family. It's a vegan-friendly, dare I say "hippie" place in Tacoma. And, as I turned to put some cream and sugar in my coffee, I saw a flyer for MadAsHellDoctors.com. It's refreshing and encouraging that it's become 'top of mind' for so many people.

But, I'm discouraged that the conversation, the debate, has become so filled with anger, mistrust, and misinformation. So, after hearing some of these concerns from those in our local Town Hall Meetings, let me see if I can adress some of these issues. And, I'll use Bob LeBow's "Health Care Meltdown" as a point of reference...nearly five years after Dr. LeBow's book was first published, it has been revised and re-released.

One of the things that keeps getting in the way of constructive conversation is the claim that healthcare reform will lead to ... rationing. Well, let's talk about that.

In chapter 4 of Health Care Meltdown: Confronting the Myths and Fixing our Failing System, Dr. LeBow adresses the issue of rationing. I've heard many say that America has the best health care in the world. And, I'm afraid that patriotism is being confused with the opportunity and obligation to examine ourselves. We can be patriotic, and still be able to point out areas which need improvement in our country. And, clearly, the area of rationing of health care is one of those areas.

Just this week, another one of those self-evident articles reached publication. (I talked about that on my post "Stating the obvious.") This article has the subtitle "Going without (insurance) coverage greatly increases mortality." Really? I guess we have to state that explicitly for those who say that all Americans (and even "illegals") have ready access to health care, through any Emergency Department. But, the article does go on to help quantify the problem of delaying access to care. And makes the claim that as many "as 44,789 working Americans die each year because they lack health insurance." The study was published this week in the American Journal of Public Health, and notes that more people die each year from lack of insurance coverage (and lack or delay of care) than from kidney disease. (Of course, if you have kidney failure, our government will give you insurance to pay for your care, including dialysis, regardless of your income status - why aren't we upset at that "socialist" act? You have a legally-mandated right to public insurance coverage for this single health condition.)

So, this "news" reinforces what Dr. LeBow wrote - rationing takes place in America, and it leads to delay in care. And, delay in care leads to higher cost care, with lesser outcomes - people without insurance wait to go see the doctor until they "have" to, and then often have lost the benefit of early treatment, when the cost is lower and the chance for cure is much higher. As a physician working with the underserved, I see this every day...

So, let's not kid ourselves. Yes, America is a great place. And, it is not unpatriotic to acknowledge that our citizens are at risk because of the rationing that we currently have; we can do better.

Town Hall meetings...

2009-08-31T20:03:00.001-07:00

Gosh, it's been a busy summer...

I've been working long hours, like my partners, in our nonprofit medical and dental practice. We're working harder to see more and more underinsured and uninsured patients.

And, I realize that I need to spend some more time updating this blog with comments about the storm which is raging across the US this summer, as seen in the Town Hall meetings.

I'm struck by the question of one of the attendees of the meeting going on this evening, in Bremerton, where this woman asks why she had to develop renal failure to warrant medical insurance coverage. Great question!

So, I'll see if I can address some of the issues that I hear coming up so often in these "discussions." ...

Summer Seminar in Clinical Ethics...

2009-08-04T10:43:00.000-07:00

I'm out of the office this week, at the Summer Seminar in Clinical Ethics at the University of Washington.

I'm sitting in a large classroom, terraced with desktops in front of a projection screen at the University of Washington School of Medicine. It reminds me of so many hours spent in similar rooms during my own med school classes at the University of Kansas. Some things have changed a bit - projector screen instead of just blackboards, and an electrical outlet next to each chair so that I can plug in my notebook computer and connect to the internet via UW WiFi. Actually, I was the first student at the University of Kansas School of Medicine to bring a full-screen laptop computer to take notes in class, back in 1985. That was a Data General ONE. So, computers have been getting me into trouble for years!

So, I find myself in this classroom, with 150 others from around the country, talking with experts about the concepts of medical ethics. And, what a time to review these concepts...

The first case yesterday brought it into focus for me:

"A homeless man with a history of drug abuse visits his primary care physician. Overall, he states he is doing 'pretty good', but is clearly malnourished. He does not have specific medical complaints, but says what he really needs is a loan of $100 to get a 'roof over my head and some food.'"

So, the question posed to the group was, "Does the doctor have a responsibility to the patient?"

And, this brought things into focus for me because we are so embroiled in rhetoric about healthcare reform that we are losing sight of the big issues...

So, does "the doctor" have a responsibility? Well, YES! As a member of society, we ALL have a responsibility to this man. (Have you heard that story about the Good Samaritan? Try reading the story again: Luke 10:25-37.) One of the scholarly pursuits of ethics is to define the underlying principles which lead to ethical decisions, to "right" choices. And, I find the basis for addressing much of today's debate in the red-letter words of the New Testament.

So, that's why I'm here. That's why I'm working where I do. I hope that those around me can see that basis in the way in which I choose to live.

How did the class respond to the question? I'm afraid they answered in a much narrower way, by saying that the doctor had only a limited responsibility to assist his neighbor. We have our text book for the week, but I'm afraid that many of the class didn't bring the other Book!

May 30 March...

2009-06-04T15:15:00.000-07:00

We had a chance to join the May 30 March - "Health Care for All in 2009: Mothers Leading the Way."

It was a wonderful experience... I've been really struggling with the environment of our work. Ongoing demand, stories from patients about their financial stressors, and a sense of doom about the economic outlook for support of the Safety Net in our state. But, in the midst of this, I was amazed by the 6000 people, from many different backgrounds, who joined together to make the statement that we cannot wait any longer to fix the HealthCare Meltdown. It was a great "shot in the arm" for me.

I put a few shots from the day up at my Flickr site. And, I've put some links there for some of the news stories about the March. That includes a nice editorial from Carolyn Hamilton Proctor, a woman with whom it seems I might just get along, where she asks, "Am I alone in my confusion on this issue of quality, affordable healthcare for everyone in America?"

We hit the front page!

2009-05-10T07:06:00.001-07:00

_ADF5788
Originally uploaded by Doug Felts

Edie Lau and Steve Zugschwerdt visited our new campus in Poulsbo, and prepared a front-page story on the work we are doing serving our community.

This is a shot of Steve, as Chris Adrig PAC works with a patient. She, in fact, has since moved out of the area, but returns for her medical care.

A reminder of Good News...

2009-05-07T09:59:00.000-07:00

I just had to share a note about some good news...

It's been a tough day, week, month, quarter... As all of us experience the effects of The Great Recession, my practice has been feeling increasing pressure. We're seeing more uninsured patients, without any increased funding to do so, and we are watching our state cut $1,000,000,000 ( yeah, one billion dollars) in healthcare resources from the next biennium budget. That means many more currently insured people will become uninsured. You can read more about some of the implications here.

Needless to say, it's been a difficult time. We've had two rounds of layoffs, in a practice which has always been rather "bare bones" in our staffing, and leadership staff has all taken a pay cut. Don't worry - no corporate jets and huge executive bonuses here!

But, in the middle of this, I'm reminded this morning of what makes us different, and why I feel a calling to be here.

I saw a patient several weeks ago, a young woman, not unlike one of my daughters. She appeared well. She was dressed in clean and fashionable clothing. She has a strong supportive family, in the middle class. But, she was struggling with an addiction problem. We talked about some options for treatment, which are few, and I planned to see her back in the office in follow up. She didn't come back. But, she hasn't been far from my mind these weeks. I've called a couple of times, just trying to check in with her. No response. And, then today, I felt compelled to call her back. I left another voicemail.... and then, I got her call back! She's been doing well. She's in a treatment program.

I felt so relieved to hear that she's well. It's Good News! And, a reminder that my partners are doing good work each day, for all kinds of people who need our help. People in harm's way. It's a privilege to be able to work for them, to serve them, to see them come to safety and health.

Amen.

Wellbee Says

2009-05-01T09:15:00.001-07:00

Wellbee Says
Originally uploaded by Infrogmation

Thanks for Infrogmation (http://www.flickr.com/photos/infrogmation/) for posting this hand washing poster, from the CDC, circa 1964...

Back then, "CDC" stood for "Communicable Disease Center": http://www.cdc.gov/mmwr/preview/mmwrhtml/00042732.htm. It wasn't until 1970 that it changed to "Center for Disease Control" and then in 1981 became "Centers for Disease Control and Prevention" (note the plural).

Despite the name changes, things sure haven't changed much, huh!

Did you hear the president talk about us?

2009-04-30T16:25:00.001-07:00

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

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

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

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

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

But, we know that we're seeing increasing demand. And, this webpage explains that in our state, the Community Health Centers will be the primary recipients of a $1,000,000,000 state funding cut.

Washington's uninsured will increased by 150,000 people, to nearly 900,000 by 2010.
35,000 people will be kicked out of the Basic Health Plan, and will become uninsured.
A program called "General Assistance to the Unemployable" (GAU) will be cut by $43,000,000. These disabled and chronically-ill patients will see their monthly income cut to $136. (Yes, one hundred thirty six dollars!)

And, who's going to see all these uninsured? Why, the Community Health Centers, of course. After all, that's what the President said!

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

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

"Federal Government Declares Public Health Emergency"

2009-04-26T17:31:00.000-07:00

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

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

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

I have the privilege of working with a team of dedicated people, who have turned from other, usually more lucrative, career paths in order to serve the least in our community. That privilege is supported by our work seeing patients who are covered by the state Medicaid program and the federal Medicare program; these are patients who are nearly always turned away from traditional (read: "for profit") medical practices in our community. And, as part of the response to the budget crisis, not only are we (the state of Washington) planning to

reduce the number of people covered by the state Medicaid program (and therefore, making them uninsured), we are also
reducing the support for the "safety net" providers, including non-profit Community Health Centers, like mine.

(And, to be clear, where do you think those uninsured patients are going to go for care? To the local for-profit group practice, which expects a deposit of nearly $200 before an office visit? They will defer care until it becomes an emergency, or they will come to my practice, which remains "the last open door" for them for routine, chronic and preventive care.)

We are also reducing access to affordable health insurance for individuals, reducing support for the services of the elderly and disabled.

You can't turn on the radio or the TV without seeing information about the growing concern regarding the swine flu. (My favorite report is that Israel has renamed the illness, since swine are not kosher! Talk about political correctness! Oy Vey!) But, where's the concern, where's the outrage about the tens of thousands, in Washington State alone, of single moms, young families, the elderly, the disabled, who will go without needed health and social services in this "economic pandemic"? There's barely a mention of it on the local news, and little on the national perspective. (You can read the summary on the Washington State legislature website: http://leap.leg.wa.gov/leap/budget/detail/2009/so09113waycompare_0424.pdf )

Well, back to work... not only do we need to figure out how to see more patients with less resources, now we have to prepare to assist the community's response in preparation for the swine flu, err, I mean "Mexican flu" outbreak, should it come to our state...

How Health Savings Accounts Lead to Wiser Health Care Choices

2009-04-21T14:10:00.001-07:00

How Health Savings Accounts Lead to Wiser Health Care Choices
Originally uploaded by M1khaela

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

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

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

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

2009-04-09T10:31:00.000-07:00

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

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

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

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

So, with a story similar to what he related to me, the ED physician did the following tests:

CBC with differential
Complete metabolic panel
Urinalysis
Blood culture
Sedimentation rate
C-reactive protein
amylase and lipase
CT-scan of his head
Total cost: ???

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

And, the prescription? Well, it was for:

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

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

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

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

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

The "S" word... Socialism...

2009-03-03T13:04:00.000-08:00

In conversations about healthcare policy and politics, I find that someone, sooner or later, says the "S" word - socialism. And, everyone involved cringes, as though we've spoken of some dark sin, or Harry Potter's "He Who Must Not Be Named." Like Darwinism, the word takes on an emotional content that is much more than it might deserve. (The Darwin talk is for another day...) Let's take a look at what the word might mean, as it applies to healthcare policy.

That great resource wikipedia defines socialism , in part, as:

a broad set of economic theories of social organization advocating public or state ownership and administration of the means of production and distribution of goods, and a society characterized by equal opportunities for all individuals, with a fair or egalitarian method of compensation."

So, that's might be much more broad that what most of us would really mean when we talk about healthcare policy and socialism. What most of us are talking about is changing from access to healthcare being for only those who can afford it, to a setting where access to basic healthcare services is available to all citizens, as a benefit of citizenship.

The concern that most people have when they speak of socialism and medicine is that the State will be in the business of purchasing health care. (Well, I gotta break it to you - the State already is! Over half the obstetrical care in our state of Washington is paid for by the taxpayers, as only one example.)

But, what's so wrong with the idea of the State ensuring that we all have access to health care?

We think of basic education as a right of every citizen. Therefore, it's provided by the State. So, it's "socialized."

We think of security as a right of every citizen. Therefore, it's provided by the State as federal, state and local law enforcement. And, on a bigger scale, as an Armed Forces to protect the integrity of the country. So, it's "socialized."

We expect protection from fire. Therefore, it's provided by the State. So, it's "socialized."

And, I don't hear anyone getting upset that "the market" isn't allowed to determine what level of police protection I have access to, what grade I can complete in school, whether the firefighters will come to my house in an emergency.

In fact, the issue of socialism is addressed in this article on the Physicians for a National Health Plan website, describing a "consumer-driven fire department." Take a look at the commentary, and the video demonstrating the concept.

So, let's take it step by step:
1) Is access to health care a right, or only available to those who can afford it? (I've often chuckled at the sign which hangs outside a medical practice I know which asserts "Excellence in Patient Care." It seems they just left off the next line: "If you can afford it.")
2) If you think it's a right, then society has a responsibility to ensure that all members of society can access this right.
3) If our current system has not delivered on this right, then we have a responsibility to step in, as a "government of the people."

This panel discussion on NPR would seem to agree...

But, let's get past the emotional baggage of the "S" word, and "the market", and get to work on a solution!

The President's Address, 2/24/09...

2009-02-25T10:29:00.001-08:00

I was particularly interested in listening for Mr. Obama's address to congress. The transcript and video of his address are available on the White House blog, at http://www.whitehouse.gov/blog/09/02/24/The-Presidents-address-Excerpt/. So, what did he really have to say about healthcare reform?

"I suffer no illusions that this will be an easy process. It will be hard. But I also know that nearly a century after Teddy Roosevelt first called for reform, the cost of our health care has weighed down our economy and the conscience of our nation long enough. So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year."

I'm particularly interested in the approach... he mentions the healthcare meltdown as weighing down "the conscience of our nation" - that's a hint that he and I would agree that we have a moral failing in the system of healthcare rationing we have in America. (Oh, you don't think we have rationing? Just ask our uninsured if they have access to the most basic of preventive services - they don't do pap smears in the Emergency Department, Mr. Bush. Or, ask our nation's retired military if they can find a local specialist, or even primary care doctor, to take care of them. I've talked about this 'economic rationing' before...)

But, the language that is stressed most is that America demands healthcare reform as an economic issue. Finally! Someone is saying it out loud! If you can't agree on the morality issue, then I think we can all find that we should work to reduce the high cost of healthcare, as it is a significant contributor to our economic burden.

I've often told of the per capita cost of health care as it relates to my own age... In the year I was born, 1962, the per capita cost for the US in the provision of health care was ~$200. And, the money we spent on health care was something like 5% of our GDP. The latest numbers show that per capita healthcare costs are now ~$8000+, and has risen to represent 16.3% of GDP in 2007. And, the trend of an aging population and costs rising faster than inflation would anticipate that healthcare costs will rise to 20% of GDP in 2017.

How does that compare with other countries? The data reported in this article is now several years old, and lists US per capita costs as $4000 in 2001. But, the article does have a nice comparison of costs across countries.

And, the journal Health Affairs has a nice editorial piece which calls for reform now. My favorite comment in the article is the revelation of the two major barriers to reform: "Democrats and Republicans".

So, the president is positioning healthcare reform as an economic issue, and now our task is to be diligent to watch that the reform process still includes the moral issue in the proposals.

"Yes, we can."

Healthcare as a right...

2009-02-11T04:46:00.000-08:00

I've talked about this issue before - access to adequate health care as a basic human right. As my son scanned the news last night, for his journalism class, he paused on a story about this very issue. The commentator opened by making the statement that prisoners are the only Americans who have a right to health care granted by the Constitution. "Really?", he said. Yeah, really...

The eighth amendment guarantees the right of prisoners to be free from cruel and unusual punishment. And, the Supreme Court has affirmed that lack of timely access to medical care would be cruel and unusual punishment.

This comes to light as we are all reeling from the Great Recession. And, because the State of California has so many more prisoners than space to keep them, we are reminded of this right to health care. You see, a recent decision by a panel of federal judges tells California that they will need to release 55,000 prisoners, since the overcrowding conditions impedes this access to health care.

So, to extend this analogy, if the US Supreme Court were to affirm that access to health care is a fundamental human right, as does the World Health Organization and the United Nations, would that mean we would then have a responsibility to send 46 million of our citizens to another country, one with universal healthcare access? (46 million is the often-quoted number for the number of uninsured Americans; with the Great Recession, we have certainly seen the number of newly-uninsured patients in our Centers increasing.)

It's about time...

2009-02-07T07:48:00.001-08:00

It's been way too long since I have commented here; ...

We find ourselves in some new days. All of us. And, I guess, "It's about time."

At our Community Health Center, we've been feeling the changes. In the late fall, one of our Behavioral Health Professionals sent out an email asking for help. You see, she had been finding more and more patients who were seeking help because they were losing their homes. Her plea: does anyone know of any resources to help these people? The answer: No, other than to refer them to the limited shelter beds available in our communities. The Great Recession is real, and it's touching us now.

I had a wonderful chance to hear a leader in the National Association of Community Health Centers (www.NACHC.com) speak at a regional conference in October. Dan Hawkins is Senior Vice President at NACHC, and in those days leading up to the election, spoke of the differences in the candidates plans for healthcare reform. (Run this google search for "Dan Hawkins" and "NACHC" and you can see some of the work Dan has done for Community Health Centers.) The analysis of Mr. Obama's plan offered some promise. Maybe now we could do something together to get this fixed... As I did a photowalk around Denver, I was struck by the message of hope echoed in the sign, "All Together Now".

But, where are we now? The country, and the world, has turned nearly all attention to the economy, blaming greed and housing and bad business practices for the onset of the Great Recession. And, the nation and it's leaders seem to have mostly forgotten about healthcare.

And, I think back to many discussions I've had over the past few years. Discussions about how inhumane our current healthcare "system" is toward our less-fortunate neighbors. Even our previous President thought that the Emergency Department was the answer to the millions of children he had denied access to healthcare by refusing to sign the State Childrens Health Insurance Plan into law. "After all, you just go to the Emergency Room." [Our current president sees this issue a little differently.]

And, during these discussions, I'd often hear the sentiment that, if the poor people need something else from our healthcare "system", the should just use their political power to influence our elected leaders to make it happen. The poor, I'm afraid, don't have that power. If they did, perhaps they wouldn't be poor!

But, now, all of us are poor! The list of names of those losing billions to Mr. Madoff includes many people who are smarter than the rest of us. And, have you taken a look at your 401K lately? So, now, maybe the "nouveau poor" will be able to speak for the "old poor". Maybe now, we can really turn our attention to the work of creating a healthcare system for all of us. Even the prestigious New England Journal of Medicine sees that there may be a silver lining to the recession which is causing so much suffering now - finally, healthcare reform.

It's about time...All Together Now...

A new plan!

2008-10-01T13:14:00.000-07:00

We had a chance to visit Old Mill Days (http://www.oldmilldays.com/) in Port Gamble, a community near our home in western Washington this past weekend. And, like lightning, I was struck with the solution to our HealthCare Meltdown!

It came to me in an unlikely place. It was listed on the bottom of a sign in front of a carnival ride. It was a beautiful day - sunny and warm. The leaves have started to turn a bit. I could hear the screams and laughter of children, of all ages, as they enjoyed the rides. And, there it was - the solution to all the problems that plague my work week!

So, that's it! "Please, no major health issues!" Simple, straightforward. I think it could garner bipartisan support.

Now, I've got to go back to work...

"The Best Healthcare System in the World"...

2008-08-20T12:22:00.000-07:00

I'm always struck by how many of my fellow US citizens fail to see the great failings in our healthcare "system". I say "system" because we certainly do not have a cohesive, organized, orchastrated approach to providing our citizens with health care, but rather a series of niche providers, many with an entrepreneurial underpinning - we're all in it to make money! (If you've read my blog, you know that I'm a physician working as an employee of a community-owned nonprofit medical practice serving the poor, and I recognize that most physicians didn't go to med school thinking it was [only] a great way to make a living, but that we wanted to be in a helping profession. But, I would argue that the institutions of care are very much dependant upon profit, even with the best of intentions...)

I sat with a patient Monday who came in to seek care for rectal bleeding. He had met me several months ago with this problem, but couldn't find a physician willing to do a colonoscopy for less than $1400 cash. He is one of the working poor, uninsured. He has had increasing concern that something is wrong, and comes back seeking this testing again. (We are a primary care clinic, and have depended upon specialists for these sorts of tests in the past. As time has gone by, we have seen less access to specialty care for indigent patients.)

So, he tells a story that is much too common - the uninsured often delay care until disease is advanced. If, indeed, his bleeding is caused by colorectal cancer, his chances of a cure have markedly diminished by this delay.

So, do we have a great "system?" This patient clearly tells me that he doesn't think so, and wonders how his life would be different if he had access to care that other countries provide.

This report from the Commonwealth Fund shows that our "grade" as a system in the US has fallen from 67 in 2006 to 65 today, largely due to the 16% increase in the number of working-age adults who are uninsured or underinsured. That's this patient.

And, what could I say to him on Monday? Well, we'll ask our colleagues in the community and region again if they can provide this diagnostic test for you at a reduced cost to you. All we can do is ask...

Stating the obvious...

2008-08-05T10:01:00.000-07:00

I'm always amazed at medical studies which seem to state the obvious. And, I'm always wondering, "Who didn't know that"?

The most likely to elicit a response of "Duh" are the articles like "Childhood obesity linked to eating too much and not exercising enough." Gosh, that's all it would have taken for me to get published?

But, when it comes to healthcare policy, it becomes apparent that many of my friends and neighbors don't have the same experience of the needs in our community, and frankly don't believe that things are as difficult as they really are. That might be reflected in blaming the uninsured for being "lazy", or thinking that all Medicaid recipients are just "welfare moms", who will keep having kids so that the State will pay them more money. Or simply that the elderly Medicare patient can't be underserved; after all, they have insurance.

My favorite example of an unbelievable situation is that of the GAU system in our state. (If "favorite" is the right word ...) In our state, we have a public program to provide support for those who are disabled, referred to as "General Assistance for the Unemployable ". Well, that makes sense - if we have citizens who are unable to provide an income for themselves, I would argue that our rich society has an obligation to help them in meeting their daily needs.

But, listen to these words that one of my patients read on the letter which announces her enrollment:

We have decided that you are unable to work at this time based on Mental Health Disorder. ... You do not qualify for medical that covers mental health treatment and so, you must find a primary care doctor to help you explore possible medications for your mental health disability.

So, did you catch that? You are disabled. So, you deserve medical insurance coverage. But, we're providing you with insurance coverage which does not have the benefit of coverage for care for the condition which causes your disability. (And, then, goes on to suggest that your PCP just give it a whirl and see if he/she can help you, without benefit of specialty consultation, if indicated.) Incredible. But, true.

"A Moral Imperative"

2008-07-31T09:09:00.000-07:00

In the August 4 edition of American Medical News, a publication of the American Medical Association, I find some hope...

The headline reads: Ethics panel may back universal coverage, ponders access as a "moral imperative".

The article reviews the ponderings of a panel of ethicists appointed by President Bush, and "appears set to endorse some sort of societal obligation to provide health care access to all."

Gosh, isn't that what we've been saying?!?! http://www.savehealthcareinwa.org/stories/index.php, http://healthcaremeltdown.blogspot.com/2008/01/advocacy-101-workshop.html, http://kpbj.com/headlines/articles/2003-05-02-HED-16.html.

As I read the article a bit further, I must admit that this cynical old guy is disappointed that "A report is likely to be issued after the November election." And, the article goes on to talk about the panel having exceeded its expertise to attempt an analysis of our healthcare policy from this ethics viewpoint.

This is exactly the place to start a review of our healthcare "system". It really is a simple analysis. Do you agree that access to health care is a fundamental human right? If so, then society has an obligation to ensure that this right is made real to all of its citizens. The mechanism for making that right real certainly is complicated by many competing interests - political, social, economic, etc.

But, if we start at the beginning, we can figure out the rest!

Power for change?

2008-07-25T12:48:00.001-07:00

As I look over my microwave lunch today, I'm glancing at the headlines on the American Medical News for July 21, 2008. The headline says: "Health Care Access Problems Surge Among Insured Americans."

So, my first reaction was - "Duh". Just ask my partners - we are seeing more and more insured patients in our practice, particularly Medicaid, Medicare and Tricare. Tricare is the public insurance program to support our retired military and dependants. And, they are our community's newest "underserved" population. These fine Americans carry an insurance card with a great slogan - "The Best Health Care in the World". That's certainly the topic for another entry...

But, after reading the story a bit more closely, I see that the article is not about the insured among us. Rather, it reviews access for all of us - insured or uninsured. The article reviews the report from the Center for Studying Health Systems Change, which has been tracking access for the past ten years. And the report shows a marked increase in delaying and deferring care due to growing access barriers.

But, why the emphasis in the headline on the insured? Ah, that might just be the power for change... Larry Seaquist noted that 97% of voters have medical insurance. The uninsured, therefore, have little political clout. Why would they? They are typically poor or young or immigrant. But, when the headlines start talking about the "Haves" rather than just the "Have-Nots", maybe that will lead to enough power to effect true change.

At least, we can hope so. And, soon. It would be immoral for us to watch even more people die during this crisis: Uninsured People Ages 50 to 64 Have 43% Higher Death Risk Than Insured, Study Finds

Community Comment...

2008-07-24T09:09:00.000-07:00

Earlier this week, I had a wonderful opportunity to sit with a group of people in my community to discuss the state of health care.

It was an evening hosted by Gail Ross, co-founder of America in Solidarity. And, I was asked to join Larry Sequist, a State Representative for the 26th District, in talking about the state of our current system, and how we might consider moving forward. Foremost in our discussion was the enhancement of the "medical home" model, and reducing administrative costs of our disjointed "system".

The stories around the table included many who currently had healthcare insurance, but were afraid that the future would see them unable to find adequate coverage for healthcare costs. That is actually a common finding, it turns out - many Americans have seen the trend, and are concerned that employee-sponsored health insurance will become unaffordable, and that they will not be able to find coverage for their family. In fact, the coverage offered by my own employer has premiums of over $20,000/year to cover my family.

I'm encouraged that more people are becoming concerned about our failing system.

And, I would certainly agree with the editorial piece in the Seattle Post Intelligencer, co-authored by someone I'm proud to consider a colleague in this work. Teresita Batayola is the Executive Director of International Community Health Services, the nonprofit agency serving the healthcare needs of the many of the residents of the International District in Seattle. The theme of this editorial is that our priority would be to ensure that all Washington's citizens have access to affordable healthcare coverage.

For me, it always comes back to the basic question - do you believe that access to health care (not health care insurance, by the way), is a basic human right? Do you agree with the World Health Organization that health care is a fundamental human right? Do you agree with the motto literally etched in stone at the Harvard School of Public Health - "The highest attainable level of health is one of the fundamental rights of every human being"?

If you do, then all the other issues seem to fall into place...http://kpbj.com/headlines/articles/2003-05-02-HED-16.html

Miracles do happen...

2008-04-28T09:48:00.000-07:00

I was reminded of this last night, as I sat with some friends discussing the topic of miracles.

A few weeks ago, I had the privilege of being a missionary, of working on a new mission. Maybe I didn't look it, as I seemed to be doing my usual work. You see, I was able to cover the inpatient service of one of my colleagues from the community, so that he would be freed up and be able to join two of his children on a mission trip to Africa. I've heard it said that there are two kinds of missionaries - those who go, and those who stay home. I had the chance to be the latter. Several of my practice partners helped out in this service as well.

And, another doc from the community had taken a good deal of this work as well. After his days of work, he "handed off" over a dozen patients to me, so that I could continue to care for them in the hospital. One of those patients was an older woman, who was now on "comfort care".

One of the tenets of the ethics of medicine is that each of us has the right to direct our own medical care. In this situation, the patient, through the designation of a healthcare proxy, had declared that she didn't want any "heroic" measures if it appeared that she was terminal. She had been admitted with kidney failure and pneumonia, and after a few days, the decision had been made that, indeed, it appeared as though she would not leave the hospital, she would die from these problems. So, the plan of care switched from curing her to offering her comfort while she died.

When I met her, she was unresponsive, essentially in a coma. She was not eating or drinking; she was not responsive to pain, and did not communicate with staff.

Well, after I had watched over her for three days, I got a call from the nursing staff. On that morning, she had sat up in bed and asked, "What's for breakfast?"

I need to be reminded that miracles do happen. It is a privilege to witness, and sometimes participate in these miracles...

"And then I saw my church..."

2008-04-23T11:21:00.000-07:00

I haven't posted for a few weeks, and feel the need to get back "on my soapbox". I thank those of you who've noted by abscence, and encouraged me to pick up the conversation again...

I guess I'll start with some stories. I feel compelled to document these sorts of things because I am constantly encountering stories which I find unbelievable, and in fact, I'm convinced no one thinks that these sorts of things could be happening in our community.

I was on call last week, caring for our patients in the local community hospital. And, it was a tough week. I took care of as many as 24 patients per day - seven days x 24 hours per day. One night, I got a call from the nurse on the psychiatric unit. The psychiatrist had accepted a "voluntary admission" for a young woman who was suicidal. She had, in fact, been thrown out of her home by her mother that night, who said to her "You're worthless; why don't you go kill yourself." So, she walked to the nearest bridge.

As she was standing on the bridge, she happened to look over the city of Bremerton, and see her church in the distance. And, rather than kill herself, she chose to call a church member, who came to her aid and brought her to the safest place she knew - the local hospital's Emergency Department.

So, the call I got from the psychiatric unit was that the patient had experienced an apparent seizure, and therefore needed a medical, rather than psychiatric, provider to take over her care. I did so.

The next day, I found that she was medically stable. However, the psychiatrists who had accepted her initially would not take her back to the psychiatric unit, despite her desire to have treatment. The stated reason was that "she was not a good candidate" for care, since she was "argumentative". They came to write in her chart, but didn't even prescribe any medications for her. As a primary care physician, it was now my burden to treat this actively suicidal patient.

So, was she still suicidal? Well, about 24 hours after her admission, again in the night, she in fact wrote out her "will". She stated that she was going to kill herself, and she outlined who should get her few possessions, her iPod, her favorite clothes. Within twelve hours, "the system" had decided that she was safe to go home. Even though she came to the hospital seeking care, she wasn't welcome to stay in the psychiatric unit. Even though she was suicidal, she wasn't offered any medications for this acute exacerbation of a chronic underlying psychiatric disorder.

She saw her church. And, her faith brought her to the hospital for care. And, "the system" turned her away.

That's the way it happened. Believe it. Or, refuse to believe that, in the wealthiest nation on earth, we have created a system in which this patient is turned away, left to herself. There are times when I am ashamed to be a part of it.

I've gotten some comments of support and encouragement from some of you, and from friends. Thank you. Even if it seems I'm surrounded by a world without compassion, or maybe because I'm surrounded by that world, I'll keep at it. I couldn't see doing anything else.

Busy days...

2008-02-15T09:27:00.000-08:00

Things have been busy for us lately. I guess they're always busy! And, likely to remain so....

I just thought I'd take a few minutes to tell some stories. It's always so moving to me to be allowed to take part in the stories of people's lives. And, I consider it a privilege.

I want to tell you about a man I have known for a few years. He's a little younger than me; in his mid-thirties. He and his family are out patients. I recall how, a few years ago, he had told me about his concern that his neighborhood wasn't safe for his family. He was worried about having young children in a home where drug deals and prostitution sometimes took place just outside his front door. He was very happy to be able to sell that home, and move into a nicer suburban neighborhood. He and his wife have both been working hard to provide this for their children.

Well, I saw him a couple of weeks ago. His wife has had to have surgery, and is now unable to work, at least for several weeks. He tells me that he's on the verge of bankruptcy, will be losing his house, his car, and doesn't know where he's going to take his family.

In this time of political debate, I'm hearing some of my friends talk about "personal responsibility". But, I can't help but think that my patient has nothing to be ashamed of with regard to his decisions. He has kept his family's well-being as his priority. He and his wife have worked hard to provide a safe home and neighborhood for his children. And, it certainly wasn't a "moral failure" or "lack of responsibility" that led his wife to surgery. In fact, he tells me that it was his wife's work that led to the injury which required surgical care - somewhat ironic, I'd say.

Now, to talk more about that concept of "personal responsibility", I still wonder what "they" would say that my patient should do now. I get that question stuck in my head when I hear that a doctor or a medical practice has decided that they will no longer be seeing patients with (fill in the blank: no insurance/Medicaid/Medicare/Tricare...). So, if they were sitting across the exam table from that patient, what would they say the patient should do now? Okay, if you can't see them, who will? If I can't refer the man with the broken hand to the hand surgeon, what would you suggest I say to him, when I sit with him?

My wife used to take those phone calls, in her work as a medical assistant. And, she would tell patients, "I'm sorry; we're not taking your insurance." She now says that she had no idea that it meant that the patient might not get care - she assumed "someone else" was going to take care of the patient.

Well, that's my job - to take care of the patient that can't find care elsewhere. But, there just aren't enough parnters in my practice to take on all that burden...

Hope!...

2008-01-22T11:57:00.001-08:00

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

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

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

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

HealthCare Meltdown 101: The Emergency Room...

2008-01-22T10:22:00.000-08:00

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

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

and

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

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

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

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

There's a great commentary on this statement here.

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

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

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

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

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

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

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

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

Long week...

2008-01-18T12:01:00.000-08:00

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

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

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

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

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

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

Advocacy 101 Workshop

2008-01-11T12:30:00.001-08:00

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

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

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

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

Advocacy 101 Workshop
Originally uploaded by Doug Felts

Everyday stories...

2008-01-08T14:13:00.000-08:00

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

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

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

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

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

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

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

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

Back from Peru...

2007-11-07T10:09:00.001-08:00

My wife and I are back from our Peru mission trip: http://www.macmedperu2007.blogspot.com/. And a couple of things struck me from this experience...

There is a "national health care system" in Peru. That is, each of the graduates from the medical schools of Peru serve in a national system as primary care providers. Sort of like our "National Health Service Corps", but with an important difference - the patient is expected to pay for this care, and the poorest of the population simply go without care.

Or, maybe that's not really different at all. I have many patients who have deferred care until they have advanced disease due to cost, and they certainly do NOT have access to primary health care without cost here in the US. Many patients do not qualify for Medicare or Medicaid, and even our "safety net" of Community Health Centers expects payment of a nominal fee.

We did a lot of traveling during our trip - Lima, Trujillo, Chao, Cascas, Iquitos. We saw the coastal desert, the foothills of the Andes, and the Amazon jungle. During that time, we saw very few Americans. But, while waiting to leave the country at the Lima Airport, we saw two different medical teams as well. We shared the American Airlines flight back to Miami with one team, a surgical team who'd spent two weeks in Northern Peru, and were looking forward to their first hot shower! It struck me that mission teams must be a fairly common sight, arriving and departing from Lima's Jorge Chavez airport.

We also had the chance to meet three medical students while in Peru. I have some mixed feelings about their professional goals. Two of the three intend to come to the US for residency training after finishing their seven years of medical school. The US can certainly use the help; 3700 of the 10,000 physicians-in-training in US family practice residencies are International Medical Graduates, according to the American Academy of Family Physicians. We just can't find enough US-trained physicians to take care of our own.

But, what about Peru? These three medical students represent the concern of many "developing" countries - the talent that is needed to move the country forward is leaving for the US or other "developed" countries, which offer their own version of the American Dream.

While the US struggles with what has been called "expensive medioctrity", the Peruvian government has pledged to provide access to primary healthcare services for all citizens, regardless of income. This is seen in this article, published in the Spring. I'm not sure what progress has been made since that time... but I do know that there are still many Peruvians who are suffering. I've met them. And the language of suffering if universal. I've met them here, too. We are spending way too much for a system that doesn't work. And, Peru is movnig forward with a national health plan to cover everyone.

So, who's really "Third World?"

My Mission Work...

2007-10-18T06:44:00.000-07:00

I've had some great experiences in my work as a physician...

For several years, I worked with a partner in my prior practice in a group called the Christian Medical Response Team. This team served as a volunteer medical team for the Washington Department of Emergency Management, and we "trained" by providing medical care at large group events. We did many, many events, including several years of EndFest, Bumbershoot, Creation Festival, local rock concerts (some as a part of Rock Medicine, including the last five Grateful Dead concerts in Seattle), and large national Youth for Christ events in DC and LA. We provided safety for well over 1M people.

I've also had a few truly life-changing experiences as a missionary. In 1998, I spent seven weeks on four different trips to Latin America. I participated in El Nino flood relief in Peru with Mac Med, worked with families in Mexico with Northwest Medical Teams (now Medical Teams International), and lead a team in response to Hurricane Mitch in Honduras with World Vision.

My wife and I are preparing for a mission trip to Peru - we leave in ~24 hours. We are traveling to northern coastal Peru with Mac Med, working with the same pastors that I met nearly ten years ago on my first mission trip. In the past couple of weeks, I have revealed to a few patients that we are planning this trip. And, most of them have said something that indicated that they were somewhat, well, impressed by my plans to serve in a developing country. But one longtime patient of mine responded, “What, there aren’t enough poor people in Bremerton for you?”

There it is! My work is a mission. I work with a missionary team of 137 other people, the employees of my Health Center.

I certainly have reason to be impressed with missionaries who serve for years, like my old Doctors Clinic partner Perry Jansen and his family (http://sim.org/index.php/project/96555) who have been working in Malawi for the past few years. And, we have a nurse practicioner who works with us for a few weeks each year, during her "break" from her and her family's work during the rest of the year in Nepal.

And, I'm impressed with my partners (providers and support staff) who have been dedicated to this longterm mission for nearly twenty years. And proud to be a part of that.

"So, what's a Community Health Center?..."

2007-10-05T13:15:00.001-07:00

After my residency program, I started my practice by joining a large medical group here in Kitsap County. I worked there as a family physician, including the delivery of OB services, for eight years. I then took a job as Medical Director at my current practice, a Community Health Center.

I must admit that I had no idea what a Community Health Center really was until I started having lunch with Dr. Bob Rozendal, our previous Medical Director. At that time, I had been working in the community for a few years, and thought I had a good understanding of the health status and needs of our community; I couldn't have been more wrong.

A Community Health Center is a practice which is partially funded by the Federal government as a grantee of the Bureau of Primary Care, one of four bureaus of the Health Resources and Services Administration. Other names which might be applied to this practice model include:

Federally-qualified Health Center ("FQHC")
"Safety Net Provider"
Federal 330 Clinic - named for the section of the Public Health Service Act which authorizes funding for this program.

To quote the Bureau of Primary Health Care's website:

"Health Centers are community-based providers of comprehensive primary and preventive health care and enabling services to medically underserved populations. Many Health Centers also offer comprehensive dental care and mental health and substance abuse services."

What we are NOT as a Health Center:

We are not "owned/run by the government." - We are an independant, nonprofit agency, which is "owned" by the community and run by an all-volunteer Board of Directors, the majority of which must be patients whom we serve.
We are not one national system. - There are ~1,000 different Community Health Center systems across the country, with about ~6,000 delivery sites. Because of local ownership and patient-driven Boards, each Center works to meet it's own community's needs, and may offer markedly different services.
We are not a "free clinic" - There are wonderful people doing remarkable work in Free Clinics across the country, as seen at the website for the National Association of Free Clinics. We charge patients on a sliding fee scale based upon their ability to pay.

Notes from the daily life of a "specialist for the poor"...

2007-10-04T11:26:00.000-07:00

When I entered medical school, my father would often offer me his advice about the choice of a specialty. He would say, with a chuckle, that I should specialize in "diseases of the rich." (Perhaps this was not just a joke - he was paying for college and helping with medical school costs, and I owe him a debt of eternal gratitude for the gift that he and my mother gave me in allowing me this life.)

I recall during my application for medical school that I, like many of my competitors in the interview process, responded to that expected question by saying, "Of course, I want to be a family physician, so I can serve the community, the needy, relieve suffering,..." But, perhaps unlike many of my colleagues, after enjoying each of my rotations, I did decide on family medicine. And, I had no idea that it would lead me here.

I took my two-month anesthesiology elective rotation first, so that I could force myself to get over my fear of poking people with needles. I achieved that goal, and enjoyed the intellectual stimulation of the daily physiology experiments, and considered that as a great option for a career.

I took rotations in cardiology, and pediatric oncology, and psychiatry. Each with the excitement of learning from remarkable men and women, becoming part of a truly noble profession. And, imagining myself as wise and compassionate as these mentors. But, ultimately, it was family medicine that kept me. I completed my residency, as Chief Resident, at the University of Kansas School of Medicine in 1992. With much of my education still to come...

I am the Chief Medical Officer for Peninsula Community Health Services, a "safety net" provider in Kitsap County, Washington. And, despite my father's repeated advice, I now know that I have since specialized in "diseases of the poor." I'm starting this blog so that I have a place to tell the stories of my daily work. It is named for the book "Health Care Meltdown: Confronting the Myths and Fixing Our Failing System", by Robert LeBow, MD. Dr. LeBow was a Peace Corps doctor in Bolivia, the Medical Director for the Terry Reilly Health Services in Southwest Idaho, and a past President of Physicians for a National Health Program. As described in this USA Today article, Dr. LeBow came to know about the Health Care Meltdown from "both sides of the bed", having suffered a head injury from a bicycle accident which ultimately resulted in his death. I had the great privilege of getting to know him and his wife Gail via email after his accident, and consider his book an excellent primer on the issues of our failing health care system.