I work in a Community Health Center and as such we see the folks at the bottom of the health ladder, well more like health string these days.  It must be that time for the HMO’s to come suck the marrow out of the bones of the state insured patients.

How so, you ask?  We, the physicians, are flooded with requests to change medications. Change? Well yes.  We need to use cheaper, not necessarily better for the patient, drugs for the patient to keep up our end of the deal.

Deal?  Well yes.  It would be inconceivable that we, the physicians, would not wish to enhance the fortunes of the struggling pharma boys (and girls – to be PC).    By ‘re aligning’ these medications, we can save, well a fortune (not for you buddy !!) for the struggling and underdog HMO’s.

Each year its the same, although the names change to keep the corporate profits spread like marmalade across companies. We get letters to inform (me) that some poor schlep of a patient has been provided with a transitional supply of prescription X while I go to look up a cheaper chicken.  The instructions are voluminous and there is room for exception.  Exceptions of course need be filed with the proper authority no doubt in some basement with missing stairs kept in the file cabinet guarded by a jaguar, though they’d like us to think that this process is made for ‘helping’ the patient.

There is an implication within all this, a copy which has, of course, been forwarded to the patient, that the profligate doctor (that would be me) has wantonly wasted the monies of the HMO.

Nowhere does it say that this is being done to save monies for some of the richest greediest corporations on earth.  Nowhere does it imply that these monies saved will go to their bottom lines.   In many ways this IS the koan of capitalism: make the little guy work so the big guy gets bigger and maybe some of this goodness, probably not money, will rain down on you.

So much for the marrow. What will they suck next.

But- I digress.

A patient appears at our primary care clinic on Friday. Classic signs of cholecystitis (gall bladder attack).  We hustle her by transport to the emergency room. Monday morning she’s BACK!  At the emergency room, the nice physician gave her the name of several surgeons she could call to have her gall bladder fixed. None take her insurance.

An 82 year old lady lives in her car. Bernie (this is too good) Madeoff with the retirement funding. She can’t afford the taxes. She lives in her car.

A patient comes for diabetic medication, gets a glucometer (to measure the sugar), strips (to use in the machine) but the company doesn’t pay for the lancets to draw the blood from the finger. Urmmmmmm.

A patient drops a heavy object on her foot. She goes (of course) to the emergency room, diagnosed with a fracture but referred to the clinic so that she can have a cast put on.  She is uninsured.   I might add this over a five day period.

A patient comes with a kidney infection. No problem. Antibiotics. Oh – we don’t cover THAT antibiotic.

A patient, finally stabilized on psychiatric medication shows up for a refill. UhOh. You need a prior authorization. What? This patient has  been taking this for a year. No matter. We need to consider the forms (they say) to make sure the patient is getting the best medication. Insurance oversight.

A letter arrived the other day from one of the major drug companies letting us know that they are going to be direct advertising to consumers for certain drugs so that they (the consumers) will know what best to ask for.

A young boy comes having (as children are wont to do) leaped off a picnic table and stepped on some glass. The local ER (no problem) sees the child, recognizes that there is glass ‘somewhere’ in the wound, sews up the wound, and sends the parents off in search of a surgeon who will see them on state insurance. Two days later. They arrive at our clinic looking for guidance. We are fortunate to have some favors to call in. He gets care.

Lest you think out there that is is a factor of my particular city, its not. As I speak with colleagues around the country, this is the rule not the exception. As insurers tighten the profit noose, looking to their bottom lines not yours, this is a frightening and every more common occurrence. As hospital emergency room expenses rise the quest to slide more care out to the community increases. Its shoddy. Its terrible. Its not good medicine, hell its not good care in the third world. It is however our current system.

Healthcare reform may change some of this but we are only at a beginning. I praise Paul for bringing a bit of humour to what is, for me, a very black, dark sad subject.

State legislatures, not to be overlooked are trying their best to carve themselves in our out of the new Heatlhcare bill by blocking advances or by shouting states rights.  With hard economic times, its easy to get voters to hear the shouting but miss the salient points.

We’ve missed the boat, again. Smoke and mirrors and distraction reign supreme. The emperor, or his bill, have no clothes. This does not cover a majority of the uninsured. I’m waiting to see how those who are unemployed, now some approaching the 2 year mark, will pay for this bit of fluff.  The state’s assistance systems were already at a foundering point and shoving the burden to physicians and hospitals for the under and uninsured will only exacerbate the problem.

There’s a bit of shuck and drag going on here. We’re told that we need to work to pass this. We’re told it will bankrupt us. We’re told this is socialism at its worst.  Socialism?

Today one of the walking wounded comes to the clinic. She works 40-50 hours a week, full time  she’s told, at one of the local hospitals. To expedite services the hospital contracts out its housekeeping. The firm, to keep profits ripe,  they don’t pay insurance.  Hmm. Ok. We took what was a paid in-house position, took away the benefits, hired the same folks to do the same job so that the profits would stay as high as maybe ….

I digress. Here’s a full time working person with no insurance.  How is a public option for her, socialism?  From where I sit, we pay into the medicare system.  We pay it in wages and taxes and reap a long term benefit devoid of the need for stockholders to benefit. Although an inconstant fiduciary, generally governments have handled trust funds much better than banks or insurance companies, always looking to the next gaming table, ripening the profits.

If we allow the loud shouts to take back the minimal advances, and I agree its far from perfect, we’ll end up with still more uninsured.  The hidden cost of the ‘uninsured’ long patched over by draining high end payments from private insurers into the unbalanced pot is at an end. The insurance blokes, have cut off that avenue. The uninsured now go to emergency rooms, expensive care, and not much of it.

Emphasis from the Healthcare Plan was on primary care, extending to patients the ability to see and to find competent expert medical care. If we persist at deconstructing the fragile imperfect house, we’ll have but a very expensive house of cards fallen loosely and very expensively apart.  Threats of Medicare cuts are more thunder than substance. We do need government to help us. Watch carefully.

The clinic, founded by members of Pop-Wuj Spanish School, (http://www.pop-wuj.org/)  a non-profit school for teaching Spanish language, and Dr. Jonathan St. George, an emergency department physician at Weill Cornell Medical Center . Dr St. George began with a space and a concept and has with coordination with the Timmy Foundation staffed a regular clinic with a full time physician and assistants, recruited a part time dentist and a part time community physician to work in the clinic.

Students of medicine or allied fields attending Pop-Wuj Spanish Language school assist with chores and triage at the clinic in the morning and then attend their language classes in the afternoon.

It is planned for the clinic to be self sustaining.  To derive funds, we will offer continuing medical education courses in Travel and International Medicine. the staff, all volunteer, will make the courses available, and the fees used to fund the clinic and operations.  We plan to use Open Source Training tools as a basis for online and study courses both for Pop-Wuj school and for Access Medicine, the teaching wing.  We hope to prove this funding model within three years.

The installation of FreeMED was not without its problems. Servers donated by SGI/Rackable Systems complemented laptops donated by Jeff’s employer helped get us off the ground. Immediate problems with infrastructure, the system wasn’t at all grounded coupled with a need for stable power, necessitated the purchase of a UPS to protect the servers.  Difficulty with the structures which are of concrete and re-bar hindered good WIFI transmissions within the building. We capitulated and wired the building for CAT5 (ish). I say “ish”, because the local wire is probably CAT3 maybe. We didn’t have any interference problems that we could pick up.

Once hooked up, we split the system for registration, triage, physicians and pharmacy. Registration has been by hand and is transiting well to the electronic system. The intake person has good aptitude with computers and was a quick study with some help. Triage, which is really vital signs and complaint are done by visiting medical students. An immediate difficulty is that the person in this position changes sometimes several times during clinic hours. There is very little regularity and registering each of these people will create some problems. At the moment, we’re continuing to register each person in the system and privilege them as such. The suggestion, by some, that we create a group without name, is problematic from several standpoints.

Physician training was minimal because of initial delays in deploying the system. However, I spent time with the physicians and we have enabled remote secure access so that they can use and manoeuvre through the system. For the most part, physicians are not the stumbling block.

There is a large pharmacy and much of the medication for patients is dispensed from this bank of medications. We did not pre-enter the medications and are still working ways to get some handle on the bulk of and entry of these medications.

The dental portion of FreeMED will be implemented once the medical is stable and in use. FreeMED continues to evolve. There were some specific changes made to accommodate the needs of this clinic and its staff. We hope to have some hard statistics from the program by mid year with full integration of the old (paper) medical records. The Fujitsu corporation has donated scanners which will enable us to port paper records into the system.

Once we have fully implemented FreeMED in the clinic, we hope to add Android capability to the Xela system, allowing for remote access as well as telemedicine conferencing.  The Android capability, already built into FreeMED permits recording and transcribing of teleconferences directly to the medical record. Other Android features are planned. FreeMED does work seamlessly to provide access by Android to appointment and other portions of the system including the internal messaging system.  There are other anticipated donations of medical equipment including monitors to the clinic. Those too are planned to be integrated using the SHIM portion of FreeMED.

FreeMED is an opensource GPL-licensed product, in use worldwide. FreeMED recently announced the release of the 0.9.0 beta version. More information is available through the FreeMED website.

If you are interested in helping with the clinic either by donation of time, energy,  equipment or monies, please contact donations at popwujclinic dot org    Another trip to the clinic is planned for May. If you have an interest in international or travel medicine and wish to contribute by taking the offered courses and /or contribute expertise contact.

We have arrived.  The medical brigade to Pop-Wuj has landed. We arrived on different flights but managed to coordinate being in the same part of the air terminal.  Customs went very smoothly although one of the bags with the primary server didn’t make it; it will be found an delivered soon (probably a mix up at Miami-Dade airport).

Out goal. Set up FreeMED for use in the Pop-Wuj Clinic.  The crew this week is here to work the medical clinic, assist Dr. Meg Sullivan, the clinic director and install and fire test FreeMED as well as transfer as much of the medical records as possible.

Our bus met us at the airport and quickly loaded the crew and luggage. Its a four plus hour trip from Guatemala City to Quetzeltenango, more often referred to by its K’iche’  or Quiche name, Xela.

Many of you may have read of mudslides in the Guatemalan Highlands The roads show evidence of the slides with many washouts of the roadway.   There were active drops with the busdriver, doing his usual Monte Carlo style driving weaving in and out of one way and two way highway areas on CA1-WEST.

We stopped to eat lunch along the way at a small restaurant nestled in the highlands. There I have my first coordinated pictures of the the team, minus me at this point. The lunch was a variety of foods common in the region, a bit more that we would normally have done for an interim meal, but satisfying.  Back on the bus for the last 2 1/2  hours into Xela we arrived about 6pm local time.  Most of us are at Casa Manen, a local bed and breakfast.  Shelley chose, as I will next week, to live with a Spanish family.  We dropped Shelley at Pop-Wuj and will rejoin with her in the morning.

Because of the two hour time shift to Guatemalan time, although we’re all a bit wasted from the trip and the planes and leaving New York at 4AM its only 8 local time.  The crew goes to a local restaurant over looking the Plaza for some sit down and group building.   We’re all pretty revved about the morning and the week to come.

Bed time, well room time about 10pm in Xela.  These blogs will be about 1 day off because of the local time changes, but I hope to have more pictures and more local interest shortly.

As a clinician I tail around one of the local doctors, Dr. Christian.  He works Tuesday, Wednesday and Thursday’s at the clinic and does a small wound clinic on Tuesday and Friday mornings.  Although there are many out-clinics — helping in the pueblos, the clinic here is run regularly and the out clinics when there are volunteers or students to help with managing the ‘stuff’ of setting up a clinic away from a home base.

The most surprising and yet elemental thing for me is the similarity of the patients here and at home.  Our first wound care was an ulcer caused by a hot water burn. She has a fluid load and some swelling as well as some mild but growing venous stasis.  Wound care here is much the same, debridement, support.

Our next, came without her support hose.  ”I left them at home today”, she said. When challenged about wearing the stockings regularly – she doesn’t. They itch in the late day when the sun is up and out. I gave her a strategy to wear them only in the morning.  She laughs, the way my patients in the states do.  Dr. Christian and I exchange a knowing glance. She might.  She gives us both kisses and warm handshakes.  Its all the same.

More patients. There are a lot of musculoskeletal complaints here. People use their bodies as handcarts. From the women who cary 20-30kg loads on their heads to the men who carry 100kg sacks of dirt or stone or concrete on their backs using a headband, the difficulties are related to a harsh life here. None of that is evidenced in the clinic – they are all grateful to have care. No one pushes. No one shoves. There are children everywhere and most of them a bit bashful.  Being nearly 1/3 taller than most I look rather giant to most of them.

The line trickles in and in two rooms with some seen on the cuff, we see 63 patients in about 5 hours. The care? First rate given some of the limitations.  There is no EKG.  Blood pressure monitoring is done in a clinic where you can scarcely hear yourself let alone small variations in sound. Medicine is, for the most part donated and solves many of the problems.  There isn’t much polypharmacy here. Even older folks walk nearly everywhere.

We are trying to install FreeMED but the problems not forseen are overwhelming.  Although there are three pronged outlets in the clinic, none are really grounded.  Wiring to light fixtures appears as if done with bell wire. The WIFI unit in the school isn’t readily accessible (a minor problem). The clinic too needs some reorganization. A lot of donated stuff has been in boxes awaiting trained and eager hands to triage (yup triage) the medications. Overall it gets done.  Our primary server got mis directed in baggage and we’re waiting for it to be delivered. The secondary waits.

Jeff and I are staying at a Bed&Breakfast called Casa Manen, about a mile (all uphill) from the clinic. We’re getting used to the altitude, about 8500 ft here in Xela.

Tomorrow we go to an outlying clinic about 1/3 of the way to Guatemala City to deliver health care to a small pueblo. We’ll be mounting the entire team plus medical students who are here to learn Spanish at Pop-Wuj. There’s a lot of preparation and Jeff is going to look at the organization from a systems perspective to get better grounded to bring the records out side the clinic.

Alas were this some fantasmagoric game. Its not. Its a Community Health Center.  We seem to collect them. Its partly our mission and partly our trial.  The health system in the United States has some serious problems those in power have yet to appreciate the depth of the hole, as it were.  If I were not at the center of the swirl, I would stand back and laugh at the machinations of those who worry that government will take over health care with disatrous results.

We are already at disastrous and the only thing that keeps us from total ruin are the government operated and funded programs.  I watched as our health center insurance, after all we too participate in the miasma of private for profit, stockholders take all insurance plans. Ours zipped up a mere 15% and still we face deductibles in the 1000′s, expensive primary care deductibles and rules for use of additional services so arcane that even insurance people can’t figure it out. Kudos’s,  however, to my boss. He split off the rise so that the lowest paid on our staff paid the least percentage increase (perhaps 1-2%) and the highest paid 14-16% increases.  It makes an intolerable situation bearable.

Back to the ballyhoo. Government run programs including medicare and medicaid offer some of the best coverage for care, most uniform although occasionally tricky policies for patients and even on the reimbursement side. You know that if you provide services, sooner or later, within some guidelines you’ll get paid. 

A few years ago one of my private practice insurers sent a note out that the POB had changed for remittences to an adjacent town and another mail box. For most of us it was still the days of paper forms and humans not in call centers who worked the system. The box, no surprise, was a fake. After 4-6 weeks of languishing claims, the company began to get calls about where might be the remittances. After much furfuring, badinage and general lying, it came to light that some miscreant within the company had created this false address. Naughty man! Would we please resubmit the claims, which now had a current zero day for timing – about two nearly three months out from their original date.  Someone made a boatload on that one!

The chicanery doesn’t end with the practitioners. The myriad of plans to medicare recipients, forced into a drug plan which is neither plan nor planned but a ponzi schema with a donut hole. For those of you sleeping under a rock for the past few years, the donut hole is a 5-7000 dollar shortfall which the medicare recipient must make up once the generosity of part D, we can’t negotiate price, plans have run out, leaving the senior holding bag, or readied to make the next payment on the stockholder’s investments.

If I offer a solution, its to step back from rhetoric and revisit a public option plan. Its not necessary to prop up the multinational corporations. We are the only quasi-civilized nation to be so hogtied by the greed of our corporations. To be sure other countries have found themselves, recently, at a shortfall because of the ill behaviour of organizations to big to fail, or perhaps to big to continue. 

Consider this:  the health of our citizens, much like their education is an investment in the future of our democracy.

This past Friday a co-worker came to me waving a sheaf of papers. “I did what you wanted. I put the orders in the system. I’ve been waiting a month and nothing (emphasized with the sheaf of papers) shows up on the computer.”
Nonplussed I asked “What’s this about?”

(as if to a small child) “I take the sheets. I put the order in the computer and then I write “SCANNED” on the paper. Its not showing up!  This system doesn’t work at all!”

I look at the desk and sure enough there’s a pile of papers, each with “SCANNED” written on the face.  (I did manage a straight face). ” You really need to send them downstairs to BE scanned. Its a machine”

I thought this would be the end of it. Yesterday one of the other team members tells me she was button-holed on the stairs about why nothing is showing up yet in her orders when she did everything we’d asked.

Well…. almost everything.  Technology advances.  People Stay the same (with apologies to Leigh Rubin).

I get a call the other day that a kid has stepped on a piece of glass. Its off hours but I say “sure, bring him in, I’ll take a look”.

A pale frightened 13y/o arrives at the clinic with parents. Apparently yesterday he jumped up off a picnic table (in the way that 13 year old males do) and sprang directly onto a wine glass lying on the ground. The glass shattered into the bottom of his foot. The parents, correctly, take him to the nearest emergency room. He waits approximately 3 1/2 hours since its “only a bleeding foot”. Xrays show glass in the wound and the physician diagnoses tendon injuries to the tendons of the toes. Ahh, you say, a case for the surgeons.

Not so fast. He has a state option child health insurance. They sew up the foot (with the glass inside) and direct him to a private practice clinic the following day. He continues to bleed, slowly, through the night. Mom and dad pack him off to the local recommended doctor only to find that he (nor most others) do not accept this insurance. They are tempted to return to the emergency room but call me.

He cannot be treated here. He needs advanced care which we cannot offer to him. I make some calls with the assistance of our pediatrician. He’s transferred to a tertiary care facility. By 4PM he’s in an operating room and being cared for.

What went wrong? Why didn’t the emergency room transfer him inter-hospital when they realized they had a severe injury they couldn’t handle? Why did they refer him through out patient when clearly there was no real outpatient option?

Insurance. When the insurance pays so poorly that even the most basic of services are covered but lose money, then the hospitals, left to chose to bleed monies or to restrict services chose the latter. In the land of ‘the best healthcare” we are forced into rationing that healthcare based not on need, not on priorities but on the needs of the stockholders of insurance companies.

Sadly folks, the Puritan’s didn’t have it all that wonderfully. Life was hard but it was short. There were no antibiotics, no x-rays, no casts, no real surgery (with anesthesia). Hospitals were to be avoided as pest houses and physicians themselves at the time knew they did little for their patients. Some cures were probably worse than the diseases.

If we have modernized medicine, why can’t we modernize the way we provide care for our citizens. Why do we in the land of the brave, home of the free, live with a 3rd world medical care system. Sure people come here. The Sultan of Brunei came here and got wonderful care. M. D., a fictional name, in the north end of Hartford got turfed. Hmmm. Would the divide and provision of care have to do with money?

Indeed it does. The wheels grind exceeding slowly for those with limited funding.