Pregnant and Uninsured:

i had a follow-up visit from a pregnant patient. she had seen me two months ago for initial medical care while awaiting Medicaid approval. turns out her husband, who works three jobs, makes a little bit too much for Medicaid so they didn't qualify. of course with three jobs, he's uninsured since none are full time.

i put this out on the blog to make a clear point that one of the most basic and beautiful human functions - pregnancy and birth - can turn into a financial nightmare for parents. i know some people who call themselves conservative (what exactly are they conserving?) might say "so what." " if people cannot afford to have a baby, they shouldn't have a baby."

i'd like to point out an uncomfortable truth. it is not expensive to be pregnant, or to have a baby. it's actually free, unless you happen to crave really expensive food, something like caviar braised lobster in a bed of godiva chocolate.

what is expensive about pregnancy and birth is the systems put in place to "manage" and "care for" pregnant women. a hospital birth has a price tag around $2000-4000, if it's normal. $5-10,000 if it's a C-Section. Prenatal care, including labs, can cost around $500-2000 as well. high risk pregnancies can be alot more expensive, up to $30,000 or more.

now consider receiving your care from a midwife. midwives are a diverse group, some emphasize labs and technology more than others so there will be a wide range of costs. i've seen charges, including necessary labs and a few home visits for the newborn baby, ranging from $800-$1500 and up.

in New Mexico, there is a vibrant and healthy midwife community. birthing centers exist and more are opening. midwives are organized politically to help shape Medicaid policy. yet many patients choose expensive hospital births instead of midwives and the overwhelming reason is FEAR. groundless fears.

For example, this patient was told she has a high risk pregnancy because she experienced 2 months of hyperemesis gravidarum (severe morning sickness). she needed IV fluids a few times and some anti-nausea medications. the "high risk" statement was probably a random comment from the doctor, but it escalated her fear over the pregnancy. the truth is that women who have morning sickness usually have stronger pregnancies. the nausea is caused by higher levels of hormones put out by the placenta, which is doing it's job vigorously. of course the vomiting can cause dehydration and pregnancy complications but the solution is very simple. access to affordable health care with IV fluids and nausea medications. this is not a "high risk" pregnancy.

a preaching moment: as doctors, we need to stop perpetuating the myth that pregnancy is an illness, that it is dangerous, that hospital birth is safer than home birth. we need to learn how to differentiate high risk from low risk women and counsel women and families appropriately. and at the least, support women and families that want a more natural approach to a very natural biological "process" - BIRTH.

andru

Another marker of success at the office?

today an older couple was referred to me by a physician working at Lovelace (our local for-profit hospital system owned by a corporation out of Tennessee). I've never heard of this doc and have no idea how the word of mouth traveled. the patient is a 59yo male with complex medical problems who is uninsured, cannot qualify for disability, is a few years away from Medicare eligibility and is in a load of trouble. signs of heart failure, liver failure, cellulitis on his right lower leg with profound bilateral edema to the knees; still smoking cigarettes and drinking alcohol (5-6 per day). he was stable, communicative and able to commit to a course of therapy which includes daily clinic visits until his symptoms are under control, otherwise i would have had to send him directly to an ER...

in the language of my past, i would have called this a "system dump." this man needs thousands of dollars worth of studies just to figure out his current baseline and then alot of medical visits to optimize his chances of survival, something a for profit system with a committment to their shareholders isn't going to tolerate.

in the language of my present, this is a man who needs help on alot of levels. he has clearly abondoned his own future and yet his one wish, when you ask him, is to live a long healthy life. his wife tells me he has heard the same information i shared about diet, medications and quitting alcohol numerous times and cannot find the willpower to make the moves. i tried to put some fear into him, realistic fear because the guys in trouble. he has recent blood work showing decreases in all his electrolytes and significant anemia... ominous signs.

the fundamental deal from my perspective is not the pathophysiology of heart failure but the failure of his survival instinct to kick in and motivate him to make radical changes in some basic aspects of his life. without that survival desire, without this man acting as his own most personal ally, what can anyone else do for him but hold his hand and comfort him in his final days?

so if i have a bit of success in calming the man's most acute problems, my next step is to understand if his apathy is from some kind of dementia, depression or hopelessness and then figure out some kind of remedy that gives him back his future. if he has already completely abandoned ship, ain't no way i'm going to try to paddle it for him. we each have to know our limits.

andru

ER Dilemma:

what would you recommend to this patient?

37yo woman comes to see you in your clinic with swelling on the right side of her face, around the lower jaw. worsening for a few days. fever, chills, painful to open jaw or chew food. you diagnose a parodititis and due to poverty circumstances you try an injectable 24 hour antibiotic, ceftriaxone, with the knowledge that if it worsens overnight she knows you are going to recommend an ER visit with hospitalization for a more powerful antibiotic that has to be given intravenously every 4 hours, Nafcillin.

it's now day two, 6pm and she hasn't shown up in your clinic yet. when contacted by phone she says she just got off work and is feeling worse.

do you send her to the local public hospital? after calling there you find out they have no beds available and a long waiting list of people in the ER. if seen in the ER it will be a long long wait and they may or may not make a good decision about her care given the extenuating circumstances of how busy they are. she will likely qualify for at least 40% off her bill when it's all done.

do you send her to the non-profit "religious" hospital? the charges are much higher but she might be able to beg for a discount after care is done. i've had a handful of patients walk out of big surgeries or ER visits and have ZERO debt.

do you send her to the for-profit hospital? not a chance.

herein lies the rub for poor people considering ER care. it's a total gamble. public hospital with long wait, poor care, big bill or non-profit hospital with better basic respect, shorter wait in ER and a small chance for ZERO bill or a REALLY BIG BILL.

toss the dice... welcome to healthcare in the most powerful country in the world.

andru

STATE of INDIAN People's HEALTH

Sunday, January 22, 2006

Indians Call For Better Health Care

By Jackie Jadrnak
Journal Staff Writer
More than a half-century ago, federal Indian land was ceded to Bernalillo County to build a hospital.
The 1952 contract transferring that land said 100 hospital beds would be dedicated to Indians, and their care paid for by the federal government.
Now, Native Americans are asking what happened to those beds at the University of New Mexico Hospital.
"You have an unmet responsibility," Gidget McCook, of Sandia Pueblo and Northern Ute heritage, told UNM regents, hospital officials and Bernalillo County commissioners last week.
"If you won't provide the services, give us back the land," said Johnnie Belone, a Navajo from Window Rock. "Don't just look for money every time you see a patient."
Their comments came during a public hearing on health care access, particularly for low-income people, at UNM hospitals and clinics.
Steve McKernan, chief executive officer of UNM Hospital, declined to discuss what is required under that contract. Spokesman Sam Giammo said the issue is complicated.
"There have been four amendments to the 1952 document, two new leases and a new federal law since then," he said. "What was stated in 1952 would not necessarily stand today."
Native American attention has turned to that contract as they have had an increasingly hard time getting health coverage. The Indian Health Services clinic in Albuquerque, for example, has
stopped taking walk-ins.
Indians going to UNM for health care may qualify for indigent funds from their home county, or for the UNM Care program if they are residents of Bernalillo County and their income is low enough, according to Dr. Ron Lujan, a Native American and former UNM Hospital board member.
"But that deletes the obligation of the federal government," he said, adding that federal programs often deny coverage to Indians who move off the reservation. Their own tribes, in turn, may deny care at their clinics if a tribal member has lived off the reservation for a period of time.
Gregg Pohuma, a native of Taos Pueblo living in Albuquerque, said he has been struggling to pay for anti-rejection drugs after a kidney transplant. IHS won't pay for his medications, he said, and UNM won't, either. He has been trying to save money to buy them, he said, but sometimes faces the choice of buying food or medicine.
"One time, I'm ashamed I took the medicine, and took food out of my family's mouth," he said. "That's something I don't want to do ever again."
The health care system needs to be revamped for Indians who fall through the cracks, Lujan said.

------------------- blogger's commentary----------------------
when you think of healthcare for native americans, what comes to mind?

1. they are all insured?
2. they all have healthcare?
3. i never even thought about it?
4. the tribes provide healthcare with casino gambling money?
5. the united states government, by treaty obligation, provides healthcare for native americans?
6. there's something called the Indian Health Service, don't they take care of it?

There is only one truth to Native American health care in this country - the systems are underfunded, shutting down services, large segments of the Native American population cannot access specialty health services or urgent cares, Native Americans living off reservation in cities (even cities with large Urban Indian populations) are treated like second class citizens often bounced from system to system and funding stream to funding stream. The "system" is a mess and is harming people.

There are a few things to know if you are to try to understand the painful complexity of healthcare financing and access for Native Americans.

1. Native Americans are U.S. Citizens, just like everyone else.
2. The U.S. Federal Government, on behalf of all citizens, made treaty promises to every Native American person to provide healthcare, usually in exchange for land or end to hostilities years ago.
3. The Indian Health Service (IHS) is the U.S. bureaucracy that is charged with this task.
4. IHS has been severely underfunded year after year, not even receiving cost of living increases in the budget, let alone matching money for cost of inflation in healthcare. The process by which money is allocated to the IHS in the federal goverment budget is by BEGGING. Each year, IHS officials take a trip to Washington to BEG for more funds out of the Health and Human Services Budget. What i mean by BEG is that the amount allocated is not based on science, epidimiology, population health indicators, needs of the many tribal and urban communities. It is based on currying political favor.
5. Some Native Americans have private health insurance.
6. Some Native Americans have Medicaid.
7. Even with these "extra" monies counted towards Native American health, there is an average of $2 per capita spent on each urban Indian and $1500 per capita spent on each reservation Indian.
8. Compare this to the $4000 per capita average for citizens of the U.S. or $7000 per capita average for people living in Miami, FL.

Enough facts, here's how the reality breaks down:

If you are Native American and you live away from your tribal reservation for more than 100 days, you lose eligibility to receive health services there. Yet, if you approach a designated IHS clinic in a city like Albuquerque, they will now turn you away and tell you to go back to your tribal reservation. Catch 22? yep.

The United States Government is failing miserably on it's treaty obligations to the First People's of this continent. I am embarrased for my country. What has become of our word? What does a promise mean in a Christian nation that prides itself on integrity? Our broken words, broken promises are no surprise to any Native Americans i know.

more on the details of system complexity in a future post.

andru

Clinic Vignettes:

Yesterday i saw a patient for the second time. a 35 yo male who complains of severe abdominal pain. He had already been seen by GI and received a CT scan of his abdomin, a Colonoscopy, an EGD (where they look into your stomach with a camera internally) and numerous blood tests. all normal. you guessed it, he's insured. the first time i saw him i identified that he carried alot of stress around eating, he ate really fast and often would eat while working, to avoid having to take a break, so i was suspicious about a possible connection since he clearly didn't have gastritis or colon cancer from the very thorough GI tests. i had recommended that he slow down his meals, add fiber to his diet (flax seeds) and drink some aloe juice. over the few weeks he had improved some symptoms since he was no longer having epigastric burning sensations but the pain in his belly was actually worse.

mulling this over together, after about 20 minutes, we figured out that he has GAS. i feel a little embarrased that it took me a second visit to figure it out, but the GI docs actually took this man thru an entire GI workup costing thousands of dollars for GAS. turns out he was eating so fast, he was swallowing air... this case supports my experience that sometimes having insurance is detrimental to your health. those studies are not always benign.

---------------------
i took care of a man yesterday, about 45yo, with anxiety/depression. he is in a custody battle with his wife right now over their 5yo son. very sweet man but clearly distressed. a few weeks ago he saw a psychiatrist because he was feeling very angry. the psych started him on seraquel, a newer antipsychotic agent. this man took the medicine for a few days but had to stop it secondary to a very curious side effect. he started feeling LOVE for everyone. note, i'm not talking about sexual attraction, i'm talking about LOVE. he's a cab driver and he found himself telling his clents that he loved them. his comment to me was, "doc, it's a beautiful thing to love people, but this was too much, right?" :>


-----------------------
a young pregnant woman came to the clinic with her partner a few weeks ago. she hadn't yet received prenatal care because her insurance hadn't kicked in yet and she didn't want to have a "pre-existing" condition! in the interests of decreasing her concerns about the pregnancy and ensuring that she have good quality care, we decided together that i would see her until her insurance kicked in under an assumed name... wow. it wasn't like i could do anything else and still sleep well that night. it's almost like it's criminal to be pregnant and poor.


-----------------------
saw a patient today with cataracts on both eyes. she's 35yo and undocumented. after being rejected by Lion's Club for a free surgery, i steered her to the local public hospital. my assistant helped her make a financial aid appointment so that she could get registered and set up for a surgery. the staff person on the phone told us that the patient didn't qualify for any financial assistance, and couldn't be seen at the hospital. this is interesting since the hospital now has two new policies for folks who are undocumented. the first policy has been there for over a year - any poor person, no matter what their documentation status, can qualify for a fair price discount of 40%. secondly, they just instituted a new policy stating that noone would be turned away even if they cannot pay.

either this staff person is misinformed, doesn't care or is purposefully lying. we hung up the phone, called back a few minutes later and spoke with a different staff person who gave us the correct information and scheduled the patient for an appointment with financial aid.

maybe that's the way around racism or bigotry - hang up the phone when someone is rude and call back until you get someone who isn't ignorant or rude.

It's on -- future physicians in California makin' noise on health care!

Last week I was blown away by med students. I spoke at a conference on universal health care, organized by some great medical students at UCLA, and attended by over 100 medical and premedical students from ALL the southern california medical schools. The topic I was asked to speak about was how to be a Universal Health Care activist. Yikes! Umm...i dunno... do you? So I shared some thoughts on where I thought medical students and physicians fit in with the movement, and some ways that medical students are thinking outside the box with creative education and action pieces. And then I turned the 2nd half of the session into a discussion, as there wasn't another place in the conference for discussion and i'm big on reflection. We had a fascinating discussion on taking this information and translating it into further education and meaningful action. What was fascinating was that the conversation turned QUICKLY from that into the specifics of "framing" messages on the topic and it seems the med students in the session really felt that framing was the biggest issue that needed work. These folks were definitely ahead of the game, and that was fun. Inspiring med students rock :>

And these cats aren't stopping there. Way back in September, when I visited a friend of mine in San Francisco, I bumped into a med student at UCSF, Renuka Tipurneni, who shared with me that the California med schools' AMSA chapters were teaming up to pull off a coordinated lobby day event later in the year. And they did it -- at the UCLA conference, Duncan Parker, a med student at UC Irvine, riled everyone up about SB 840, the single-payer healthcare bill sponsored by Cali senator Sheila Kuehl. And from these and other medical students' coordinated efforts (thanks to Vanessa Calderon for putting on the UCLA conference, a number of other med students in Cali organizing these events, and Kao and Chris from the national AMSA office for putting efforts into it too and creating wonderful talking points on the bill), along with endless energy from Don Bechler and others at Health Care for All Cali and folks at California Physicians Alliance, more than 150 medical students are going to Sacramento to lobby on this bill tomorrow! I'm bummed I can't go, I'll be in the medical ICU at the hospital, but I do wish them all luck, and those of us who can't go are awaiting fun photos and stories from the event.

More info on SB 840, the bill they're lobbying on here and here, and a link to California Senator Sheila Kuehl's website.

The press release for the event tomorrow is below. Good luck to the med students tomorrow! Whether single payer or other related health care reform, it's great that there's positive movement and by future physicians too. Some say -- as California does, the US follows... let's see :>

FOR IMMEDIATE RELEASE

Contact:
David A. Brown
Phone: 949-241-1935
Email: dabrown@uci.edu

MEDICAL STUDENTS TO CONVERGE IN SACRAMENTO, DEMAND HEALTHCARE REFORM

IRVINE, Calif., Jan. 17th, 2006 – The next generation of doctors has a different prescription for the health of California. Alarmed by the growing disparity in healthcare statewide, medical students from all 10 California medical schools will converge on the state capitol from 12-1 PM on Jan. 17th, 2006 to demand an expansion of healthcare access to all Californians.

This gathering will mark the largest ever coordinated effort by California medical students to promote universal healthcare. More than 150 students are expected to demonstrate on the capitol steps, followed by meetings with State Senators and Assembly Members. The event is being organized by local chapters of the American Medical Student Association (AMSA), which is the oldest and largest independent association of physicians-in-training in the United States.

The rally and legislative visits will support a 2005 California State Senate bill introduced by Senator Sheila Kuehl (D-Santa Monica) that proposes to establish the California Health Insurance Agency, which would provide single-payer healthcare coverage to all residents of California. The bill, designated SB 840, passed the State Senate and Assembly Health Committee last year, and will be reintroduced to the State Assembly this year. Senator Kuehl is the keynote speaker at the rally and will address the students at 12 PM.

“That our newest generation of doctors is exhibiting such a strong commitment to universal health care means it is only a matter of time until it becomes a reality,” said Kuehl. “In a system faced with growing numbers of uninsured and medical bankruptcies, as well as rapidly deteriorating quality of care, these future doctors are acting to protect not only their future patients, but also their own ability to practice good medicine. We must listen.”

Now topping over 6.5 million, the burgeoning number of medically-uninsured state residents has sparked widespread activism and legislative action...

(cross-posted at Los Anjalis)

Vegetarian Diesel Pickup Trucks?

About two years ago I ran across a really strange idea. A few wing-nuts were talking about how Diesel engines could be powered by used vegetable oil and someone even drove their car across the country using only french fry grease from McDonalds. I was intrigued so I investigated and learned that Mr. Diesel was a German inventor who made an internal combustion engine designed to burn vegetable oil. The story goes that Germany didn't have any strong links to middle east oil reserves so they had to find their own fuels to burn around the time of the world wars. Mr. Diesel was eventually found dead and his vegetable engine was converted to burn low grade petroleum (which is from old dead animals, for the most part).

So I decided to investigate further and found some local wing-nuts who were already running veggie oil in their vehicles and were also making BIODIESEL by mixing used vegetable oil with methanol and a few other ingredients. Biodiesel can be used instead of regular diesel with no changes or modifications to a diesel engine.

With gas prices rising, and myself needing a "new" vehicle, I purchased a used Dodge Cummins Diesel, '91 Pickup Truck about a year ago. The conversion kit cost me $1200.00. I then bartered with a mechanic to install the kit in exchange for 10 free medical visits, which he donated to a local church for their poorer members.

The truck has been running great on used vegetable oil for the past 8 months, and so far, even on cold days this winter, it is doing great. The way it works is this - you start your truck on regular diesel fuel and drive until the temperature of the vehicle warms up to about 140 degreees farenheight. I installed a thermometer to help me figure that out more accurately. Then you flip a switch and the truck starts drawing fuel from the used vegetable tank instead of the diesel fuel tank. When you are about 1 minute away from your destination, you flip back to regular diesel fuel and let the veggie oil wash out of the engine. I have forgotten to do this last part a few times and mostly, there are no noticable problems, aside from an occasional rough start in the morning.

For the past eight months, I;ve been relying on my mechanic to gather the vegetable oil and filter it. he's generously only charged me $1 per gallon. Today I made a big step towards complete independence. I approached a restaurant nearby my house last week, a Sushi bar, and asked them if I could have their used vegetable oil. The mostly use it for vegetable tempura dishes so there is very little animal fat mixed in, and it's a high quality restaurant, so they don't reuse their oil too many times. I thought they would think I was nuts, but they readily agreed. Its in their economic interest because if I don't take it, they have to pay a company who comes by and collects it to make animal feed. So today I picked up my first 5 gallons of used vegetable oil and will start to filter it later this week. The filtering is very simple. You get a 10 micron "sock filter" and pour the vegetable oil thru it into a clean container. That's it. After a few hundred gallons, you get a new sock filter.

Free Fuel! Gotta love it.

andru