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.

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.

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.