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.

As there is increasing talk in Washington about the AMA time clicks by. And to whom are the insurance companies responsible? Ahhh shareholders, the same folks who brought us the current bank debacle, to whom we the people pay extravagant sums so that they can support CEO’s in a style to which they’d like to become accustomed. As there is continued agglomeration of insurers, they flock together, eat each other, thereby decreasing real market competition, in the guise of bringing lower cost to the consumer.

In medicine we speak for the patient. In insurance they speak for the money. There’s an inherent split here. When it comes down to it, shall we authorize care OR shall we make 0.02 for the stockholder, the stockholder and CEO options always win out. Duplicity is the name of the game. When Hurricane Andrew roared across the South Florida Pennisula devastating the area. Aetna group was the major insurer holding more than 4 billiion dollars in losses. That past year they golden parachuted their worthy CEO for 987 MILLION dollars (or there abouts) and then cried the blues that they didn’t have monies for claims. Hmmmm

I personally have run into the dealings of insurers. Serveral years ago one of the Connecticut health insurers sent out a note that all billing should henceforth be sent to a POB in Enfield. We all did send claims there and as weeks went by and no claims information was forthcoming, we were told that the claims were lost or that they should be re-submitted. Whoops. Someone bad in the company made an error and there is no POB in Enfield for our claims. We’re really sorry but you’ll have to re-submit them all over again. Hmmmm

I’ve had several friends who’ve suffered death at the hands of insurers, not in any direct sort of way but the usual games playing with existing conditions and difficult to access portals.

Working in a safety net group we see patients bounced from one provider to another, mostly based on non paying insurances. I think most of us are insulted when the insurers talk about the Medicare program, and how it fails to work. It succeeds with a 5% overhead, a draconian fraud unit, and coverage that most of us envy. Are there faults? Are there fixes to be made? Of course. We can in one swoop, make our system succeed. It needs a government backed program, devoid of usurious profits, not socialism, just good medicine.

We need to recenter the discussion, not about death notes but about how to prevent the needless deaths from an unwieldy bloated system which spends much of its monies not on patient well being but on corporate well being. Straight speak or soon, all the Michaels will be dead

I have always felt that we were most lucky, we are a smallish state and have a training institution and hospital which are owned and operated by the state. This hospital should be seeing the those at the fringe, those in great need. For many years the hospital was located in the center of an immigrant community. In the 70′s it relocated to a suburban location, very upscale. At first there was a bus  to take people from the community but that quickly was quashed. Now it takes two busses and a local jitney at the heath centet, about 2.5 hours, to get there. Not much of a barrier.

Patients going to his greater facility of learning often encouter trolls at the gates. Trolls? Admission to this center of ‘much higher learning’ requires the proper insurance, not some of the lower paying kinds that our patient’s possess. When they call, the answer is frequently, call back when you have better insurance.

A few weeks ago, after some harsh notes from our facility, several well dressed physicians show up to try to make arrangements to expedite the admission of our patients into the gleaming tertiary care facility, state owned and supported. To show magnanimity one of the docs takes out a card with driving directions and some special parking near his clinics. There is muffled laughter as we tell him that the majority of our patients  don’t drive nor own cars. He’s a bit culturally disconnected.

Lest you think that this is peculiar to the country estate hospital, the in-city institutions answer similarly.

Recently a patient shows on a Friday afternoon, all hunched over, the Groucho Marx walk, right upper quadrant pain, rather classic gallbladder symptoms; a surgical problem. She is referred, complete with small note from the doc, and ambulance transported to the in citty  emergeny room to prevent her from having to find transport. The attending physician there concurs but adds the diagnosis ‘shitty insurance’ and instead of wheeling Senora Patient to a holding area for surgical admission, gives her back a note with the names of two surgeons in the area saying she needs urgent and immediate care. She of course calls those offices only to find that neither surgeon participates with her insurance. Quel suprise! Monday morning, quite more hunched over she comes back to our primary care clinic, sicker, with the note and no scar. A nasty note and a phone call, she’s retransported and admitted for care.  This is a good outcome?

With all the ballyhoo about insurance companies participating in health care, and contrary to their every present advertisements that ‘they take care of you’ we need remember that there’s a profit motive totally separated from any health provision.  The recent squealing and wheezing from the health insurance companies and their paid compadres in government about the death of health care should we use single payor or government sponsored health care is quite self serving, serving only their investors.

The only investors in Medicare are we the users. Its far from perfect. It has a 5-8 percent overhead, unmatched anywhere in the insurance industry, even with draconian plans which provide and income source for the insurance companies not safety nor security for their policy holders.

We need to re-direct our efforts and energies toward providing a comprehensive Medicare type system.  A single payor system will insure fairness. I see no reason why the private companies can’t compete for business as they do in every other country with single payors. Lets see them for what they are, trolls at the gates.