Miracle Baby - Only $30,000.00!

A few months ago I was approached by a volunteer health worker in my clinic. She timidly asked me if I could help her understand her University Hospital bill. We sat down and over the next half an hour she apprised me of her situation. I was stunned, and I've done alot of advocacy work as some of you might suspect.

This is a young woman who had a rare medical complication during her pregnancy. Antibody Kell. Act of God, nothing she did. It was picked up appropriately by routine prenatal care and the patient was referred to high risk pregnancy status in the Ob Gyn Dept. She was fortunate to have a wonderful attending doctor care for her. She received the highest level of care which included four blood transfusions and ultrasounds every other day for the remainder of her pregnancy. She reached full term and delivered a healthy (and now rambunctious 1 year old) little girl. This is a "miracle baby" who would have died if not for the advances in medical technology and the determined and rigorous application of these services to this fortunate family.

So what's the problem? Well, you might imagine that this was quite costly. This patient is a savvy woman and was aware of the potential cost so she asked her doctor and social workers about the bills. They all reassured her that the "high risk pregnancy fund" would cover the cost of the pregnancy. It is state money put aside to ensure that all women have the best opportunity to birth a healthy baby, regardless of income, ethnicity or nationality. She has a signed copy of that document. But somewhere in the aftermath of the miracle her family got caught in a hurricane flood of bureacracy. Her bills were denied by the high risk fund, she went into collections and started having troubles from collectors. The total doctors bill was roughly $8000 and the Hospital portion $22,000. This was before we were able to institute the fair price discount at the hospital so she couldn't qualify for 33% off. She was stuck with an inflated bill of $30,000 for a high risk pregnancy and delivery.

After 8 months of forging her way thru the paperwork and multiple financial aid appointments, she became so frustrated that she joined our coalition and wound up speaking her story in front of the Clinical Operations Board of the hospital. They were all duly appalled and referred her to the patient advocate. In the weeks following, they met, but he reassured her there was nothing the hospital could do, the bills were already in collections and from too long ago.

With further advocacy, she managed to get EMSA (Emergency Medicaid for Services for Aliens) to pay for the delivery portion of the bill dropping the bill by about $5000. The hospital also decided to carve away about $1500.00 of her prenatal bills that were "inappropriate" charges. So she was now down to $23,500.

This is when we went to the financial aid office together. FOR ALL MEDICAL PRACTITIONERS AND STUDENTS, IF YOU HAVEN'T BEEN THRU THIS BUREACRACY YOURSELF, IT IS IMPERATIVE THAT YOU WALK THIS PART OF THE MEDICAL JOURNEY WITH ONE OF YOUR UNINSURED PATIENTS WHO HAS A HIGH BILL.

First we met with the financial aid director whom i had talked with the day before. She was super nice and agreed to shave off about $5000 more. (she also agreed to advertise my clinic to uninsured patients since UNMH is full!) But more importantly, she agreed to really look into why the bill wasn't paid for by the "high risk pregnancy fund." this was and still is the big mystery. noone there knew the answer. We then moved over to the doctor side of the hallway. The first worker we met was hostile but we were lucky in that the bill was already in collections, so "she couldn't help us." sometimes that's a real blessing. :> The next lady we met was awesome. She had a miracle baby herself, a granddaughter born too early, so she understood the CONTEXT of this person's life. My patient was no longer a number or a problem, but a person worthy of helping. She promised with a smile to look into the doctor portion of the bill and help us understand why it wasn't paid by high risk. Incidentally, I had talked with the attending doctor the week before and she remembered this patient well because the medical condition is 1/1,000,000. She was shocked and frustrated that the patient still had a bill and felt like her hands were tied as she had tried all appropriate avenues to assist the patient from the inside.

So who knows what will happen next, but something special happened for this patient and me that morning. She told me afterwards how different it was to enter that space with an advocate, a doctor, how it changed the way she was seen, felt, treated and possibly the future of her families life.

This is a hard working poor family. They love their "miracle child" and her older sister. It's a case where all the safety-net systems failed, all the doctor's efforts to rectify failed, the board of the hospital failed, and perhaps we too will fail to find justice in this case. But not before this case is sitting on the governor's desk with a big long story in the daily paper.

To imagine a whole world of lies circling around this young families lives like a tornado with hands reaching out to grab their money, voices yelling at them to pay their way, frustration paving their path to a future of debt to a public hospital.

Another world is possible.

It is time for our society to invest in the values we spout all over the public eye - Family Values. I am thankful to this patient for helping me learn my world, for having the courage to speak up for her life and the future of her family. I am thankful that I am in a position, politically, to walk that path with her. And i'm thankful that her munchkin 1 yo cute child comes along on all the walks.

:>

andru

Week in Review - September

this was an exciting week at the Topahkal Family Practice Office. Last weekend we participated in a health fair with the traditional medicine practitioners. The event saw about 200 people show up. We presented four different discussions in the morning - 1. diabetes 2. stress reduction 3. Ventosas 4. Environmental Health and Natural Soap Making. In the afternoon local residents signed up for various healing sessions from traditional medicine (limpias) to reiki to reflexology to massage. I got to hang out with some cool volunteer nurses who were doing blood pressure and diabetes screening for my clinic. and the next booth over were two local midwives, awesome folks, who just purchased a home nearby for doing home-style births for low income members of our community. they had a wonderful, explicit display of birth pictures showing a hands-off successful home birth. the display attracted alot of attention, particularly from young girls who were wide-eyed curious about this narutal process that many of them will go thru at some point.

later in the week, at the clinic, we were busy almost every day, seeing from 8-15 patients per half day. on the financial side, i made $800.00 during my four half day shifts. that's getting close to the mark for making a total of about $35,000/year after overhead and taxes. if i was working locums (or moonlighting) for the same amount of hours (22 including admin time) i would have made $1100 before taxes with no overhead cost. there are a few outstanding bills from during the week, but probably not more than $75. So far, the clinic is debt free from all the startup expenses and have a small buffer to buy meds and supplies without too much hassle. I'm feeling pretty good about this state of affairs for being only 9 months old and in a location that can only be described as "hidden," and "off the beaten path."

there were a few interesting cases worth ruminating about. a young mom came in with her son who had an injury to his pinkie. after evaluating and treating him, she mentioned that she had chronic flank pain right side and had already had her appendix removed with no relief. i like trying to figure out chronic pain so i offerered her a consultation. she mentioned that she was under eval by a gynecologist who was ordering another ultrasound (she had already had a ct scan and ultrasound a few months prior) and it was going to cost her $75 minimum up front. i did my exam on her right flank and found that she had point tenderness in the muscles between the 8-9, 9-10, 10-11 ribs, right over the liver/gallbladder and ascending colon. she also had pint tenderness at the upper part of her right hip where the muscles and ligaments attach. no organ pain that i could appreciate, no symptoms whatsoever of the GI tract, liver, gall bladder, or uterus/ovaries. the pain was slightly relieved with some accupressure held for 3-5 minutes over the muscle bellies. she mentioned that this was the first time a doctor had touched her aside from a quick push on her belly by the gynecologist. he elicited right lower quadrant pain because he was pushing on her right hip as well... who knows what it will turn out to be. i gave her the diagnosis of chostrochronidritis (rib inflammation) and heat/ice with motrin treatment for a few weeks. she needs to decide if she will followup with th gynecologist or not. it's not my style to block another doctor's workup. the thing i want to learn is this - if you elicit specific muscle tenderness on the chest of ribs or back, is that specific enough to rule out internal organ pathology? certainly organs can refer their pain to parts of the body like the back or arm or chest... i'll have to ask my colleagues their opinions on this. the unfortunate reality is that i suspect most of us doctors wouldn't really know since we don't touch our patients. perhaps some old old old timers...

the second case i'd like to muse about was a middle-aged woman with newly diagnosed breast cancer. she was in a state of shock but coping with the news and proactively trying (almost desperately) to find an immediate cure. her surgery was scheduled in 10 days and she was doing every alternative remedy or therapy conceivable. she came to me upon a recommendation of a friend of hers to see what we might have to offer. i was able to teach her about intestine and liver cleanses which will surely give her body a boost in the right direction in terms of detoxing, and at very affordable prices.

there were two aspects to this case that were intrigueing. first is that this woman presented herself to us in a very vulnerable state and if we were pushing expensive supplements or therapies, she probably would have paid anything to take them. that makes me uncomfortable. i'm sure the people pushing all these rememdies (including cancer chemo) truly believe their therapies make a big difference but the profit makes me quite suspicious. i wanted to advise her strongly to avoid expensive remedies and to try to work with a naturopathic doctor or chinese medicine doctor to make sure she was integrating the various therapies in a rational way. she had already looked into magnets, various herbs, coctions and acupuncture. this leads to my second line of thought. this was a really sweet woman feeling like there was no end to what she would do to keep herself alive. a very appropriate response. but the flip side is that she was out of balance in terms of pushing herself so hard and incorporating any suggestion that held an ounce of potential. i wound up trying to reassure her and tell her that she was doing enough already, that between now and the surgery she could relax, continue her current regimen and then assess after the biopsy results returned. i think my advice fell on deaf ears, and i completely understand why.

andru

Spanglish Joke

Como se dice "niece" en Espanol?

Rodillas.

(thanks to the six year old bilingual boy who taught me that. i still don't know how to say niece though...)

andru

"911 is a Joke", accountability, and Medicaid

Last night my brother and I went to an 80's party hosted by a fellow resident. The resident and his girlfriend went all out -- there was a glow in the dark mega rubix cube, 3 televisions side-by-side playing a videotape he put together of his favorite scenes from movies from the 80's, poprocks everywhere, bottles of beer with glowsticks in them as decorations around the apartment, and song after song from the 1980's playing in the background. My brother and I weren't sure what to wear to the party -- we totally missed the 80's altogether when we were living in it. The only thing i remember doing that was 80's-ish was pegging my jeans. I'm sure we did embrace more of the 80's while we lived it but we were definitely having some cognitive dissonance (or perhaps some active repression of those memories). So finally we decided -- Nalin (my brother) dressed as George Michael, complete with the Cross earring, and I dressed as Flava Flav from Public Enemy, complete with a bigass clock around my neck (that nalin made), a sweatsuit, and a brim cap with "Flav" written on it. I was just missing the gold spinner teeth (and I was reminded by several at the party about missing them). Others' costumes were most creative. It was my first real 80's party after the 80's, and the partygoers' way of chillin' a bit after some crazy insane long days in the hospital and the crazy insane things going on in the world.

So it's been a while since i've posted. My month on the pediatric intermediate nursery with the newborn babies has finished, and I'm almost nearing the end of my month doing inpatient family medicine. Working with little babies was more fun than I thought it would be, but I was definitely missing interactions with adults after my month in the nursery. So many stories from the wards, I'll share one specific one in an upcoming post. I'm almost 3 months through residency now, but hey who's counting? :> I still feel weird when people call me doctor, i think that feeling will stay on for a while.

It's been rough doing this intense work while things are breaking down all around. The New Orleans (preventable) disaster has really eaten at me. My brother and I have spent countless hours processing it and figuring out our role in the response, however minimal given our location and time constraints. I almost want to forego my vacation to India in a month so I can spend my only 2 weeks of vacation this year in New Orleans helping out. But at the same time, it's been 8 years since i've been to India and my relatives have planned my grandparents' 60th wedding anniversary celebrations around our vacation, and we've spend $2500 on plane tickets. Displaced folks (not "refugees") have made it as far west as Phoenix, perhaps some will make it out to Los Angeles and we may be able to help in that way. Until then, we'll do the donating and figure out how our assistance can be used in the long haul -- clinically, politically, or otherwise -- because it's going to be a hell of a long process in rebuilding lives.

Speaking of rebuilding lives, the disconnect between the national government and the people is striking. I'd like to think there's just incompetence on the part of the goverment, but it's looking more and more like flat out negligence, which is worse. The racism and other -isms against people not wealthy enough to sit at the table with Bush and Co. are overwhelming.

On a health note (and to further show the disconnect between our nation's "leaders" and the American people), Congress is looking at slashing 10 billion bones from the funding of Medicaid, the public health insurance program for low-income Americans. This has been underway for a while, but after the disaster in New Orleans, many Dems and some Republicans have voiced opposition to the cuts in Medicaid. However, many Republicans are defending the cuts by saying the two are not connected. A comment from Senator Kyl (R) in Arizona: "We need to be careful about making a direct relationship between Medicaid cuts and disaster relief," adding, "There may be little or no connection there." So there are thousands of people dying, thousands others displaced, and this catastrophe is reduced to "disaster relief" with no connection to health care? What world does he live in, how disconnected is he from his constituency? But then again, Barbara Bush thought evacuees were better off after the disaster because of all the wonderful hospitality in Texas. No worries about losing their homes and jobs and lives and relatives, because hey they're poor. And Representative Richard Baker (Louisiana) told lobbyists: "We finally cleaned up public housing in New Orleans. We couldn't do it, but God did." Let's fire him. Fire him and Kyl and all the other disconnected money-mongering rich bastards in Congress.

I've already heard several people on a few health related listservs state that we really should be focused on the rescuing and the rebuilding, not on blaming Bush and his cronies for what went wrong. Well it's hard not to blame as Bush has done SO many things wrong on this situation. Isn't it the role of the public in a democracy to hold its leaders accountable? Why do caring citizens get accused of playing a "blame game"? (Scott McClellan mentioned that term 15 times in two press conferences -- the bush press machine is hard at work). More public relations crap as Bush said recently, "We solve problems, we're problem-solvers." What? As Ed Helms reported on the Daily Show (that show ROCKS) - "Bush is often found saying 'We A - B. We're B - A'ers'" (and we just TAKE it). On the accountability tip, Paul Krugman drops science at his editorial in the NYTimes, where he states:

Why did the administration make the same mistakes twice? Because it paid no political price the first time.

Can the administration escape accountability again? Some of the tactics it has used to obscure its failure in Iraq won't be available this time. The reality of the catastrophe was right there on our TV's, although FEMA is now trying to prevent the media from showing pictures of the dead. And people who ask hard questions can't be accused of undermining the troops.

...if the administration isn't held accountable for what just happened, it will keep repeating its mistakes. Michael Brown and Michael Chertoff will receive presidential medals, and the next disaster will be even worse.

Blame or accountability, it's all a matter of how you frame it. Accountability is the damn BEST tool citizens have in a democracy.

But I digress, back to Medicaid. Drop some thoughts to your elected officials on why we shouldn't cut Medicaid of $10 billion in long-term funding. There's a form letter, you can modify it if you want. If a disaster of such proportions happens in New Orleans and we don't stop the slashing of public programs, people in the streets will indeed be singing Public Enemy's "911 is a joke".

my health insurance premium rose 100%

that's double for those of us not so good at math.

and how does this relate to the cost of inflation?

i pay for a catastrohpic health plan in case of injury or major illness. when i called the company (Celtic) to inquire as to why this amazing increase, the guy laughed at my frustration and told me it was all legal and approved by my state. so i called the state insurance guy who does the approvals. he's someone i met once a few years ago. he concurred that he did approve the increase, that he thought it was sad, said something about magnitude versus percent... and then commented that this is what we get when we live in a capitalistic society and his job isn't to question fairness, just to follow the formulas which are based on calculations on cost of increase from around the country. it was quite an interesting conversation. his advice to me, heartfelt, was to shop around. i'm healthy, he said, so i have the luxury of finding the best price.

nevermind that this same increase will be felt by families more strapped than me, by folks struggling with illness. that sums it up. capitalism in healthcare works well for healthy people with strong financial backing.

i'm on the verge of foregoing health insurance all-together to join in solidarity with the many and growing ranks of the uninsured. i was trying to be a responsible citizen and take care of myself. i'll have to think about it a bit more. i have until november to decide before this new premium takes effect.

andru

Pharmacy Research -
the excessive profit isn't just for the drug companies...

sparked by one of my patients, i did some research lately on the cost of medicines at various large pharmacies. it changed me in a fundamental way. i've had a beef with the drug industry for a while now after studying the price structure of medications, made by the same companies, and sold at hugely different prices in various countries around the world. from pennies a pill to dollar a pill difference. most recently a patient of mine informed me that she had done some comparison shopping and found that the pharmacy at Costco had the best prices. so i decided to follow her lead. i checked on the drug Fluconazole, an antifungal agent used for yeast infections and onychymycosis (sp?).

Wal-Mart: $13.32 per pill or $51.36 for 12 pills
Walgreens: $22.99 per pill or $103 for 12 pills
Costco: $7.29 per pill or $23.29 for 12 pills

go figure. and go to costco for your medications if you are uninsured. turns out you don't need to be a member to use the pharmacy, it is open to the public. it's not in my nature to promote a particular corporation but let me at least encourage folks who are uninsured to shop around. as much as i'd like to stimulate small business, the unfortunate reality in the pharmacy world is that small, local pharmacies usually charge as much as walgreens so that they can stay in business, so it's difficult for them to cater to the uninsured.

by the way, the prices at Costco are so reasonable i'm starting to buy the medications i use on a daily basis in the clinic from them. it's cheaper than what i can buy wholesale as a small doctor's office from the internet stores like Moore Medical and Besse. it also allows me to keep a stock of essential drugs that i can give directly to my patients (like antibiotics and anti-nausea meds) so that sick patients don't have to make a trip to the pharmacy.

andru