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.

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.

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

Why veto it? Governor Rell seems to have forgotten some history here. In the 1700′s the citizens of Connecticut recognizing that they didn’t want to replicate the Dickensian debtor prisons of England, established havens for those to sick or unable to work; town farms. The town farms were by no means a happy haven but residents there worked on the farm as they could, helped to be self sustaining, had some funding from the Selectman’s budget in the town and had food and clothings and housing and medical care. This, from the compassionate citizens of Connecticut. Fast forward. When larger government programs superseded the Town Farm System, the program became State Aid to General Assistance (SAGA) one of the safety net programs here in Connecticut.

No one wants to see SAGA patients. Getting referrals from primary care (I work in an FQHC) to tertiary or upper level care is nearly impossible. SAGA pays poorly for advanced care and since its coverage mostly (a devilish word) is for poor folk; Who cares. The devil in the mostly is that folks who have worked all their lives but had some dreadful disease may find themselves on SAGA. Folks who have a sickness in the family, monies wiped out by the vagaries of the current ‘he who has the gold makes the rules insurance system’ may find themselves on SAGA. The list goes on. The poor line up and are anointed with the least of the least.

Sustinet looks in ways to fix this, to level the playing field by making no distinction between rich and poor by allowing all access to health care. Bah Humbug they should pull up their bootstraps, you say. WHO will pull up the bootstraps. My 24 year old daughter recently fell into the hole between parental coverage and no coverage from work. Luckily she had her health. Needed medications, however, consumed a fair bite of her savings.

Whats with the beak dipping? Governor Rell is a leftover from the Rowland administration here in Connecticut. She distanced herself from John Rowland (who spent some time waiting for a better paying government job — quel suprise!). Republican administrations believe that business will make it all perfect. That the shareholder marketplace will bring equity and equanimity to the medical system. Each of the stakeholders will ‘dip his beak’ only taking a fair share of the monies, pleasing the boards and CEO’s. I think this more akin to crows feasting at the carcass. There isn’t much money and pleasing the shareholders never improved wellness. There is a finite supply of monies and pleasing the CEO’s and padding their golden parachutes never helped struggling parents with sick children. Dipping their beaks, sucking up the juice.

Ahh for sure, all that will be left of Sustinet will be the bones, no juice, no meat, no insurance, no coverage. And the fat cats will be daubing their beaks with linen napkins.

Ok, you think. Let this guy pull himself up by the bootstraps. He did. He got a second job. Still no insurance. Then he got Diabetes. Oops. Its not quite like a third job because you pay them instead of getting paid. You work harder. The doc says you should have less stress. Ok. I’m working a job to pay the insurance and another to pay for food, now I have to pay rent because the diabetes job just doesn’t bring in enough.

Oops.

Now you can be on state sponsored insurance, some of the time. You feel really terrible. He did. He worked all his life and was always responsible. Now he’s a ward of the state and working.  He gets headaches. He’s not feeling well. One day he falls. He goes to a doctor but they can’t see him because his limited HMO insurance wants him to see a doctor 40 miles south. He bucks the system but there are not many alternatives.

Finally he gets an appointment with neurology.  He has a grade 4 astrocytoma; not a good prognosis. Although he has insurance for this and has coverage, because of his limitations (he has memory lapses and poor focus) after the tumor is primarily removed,  he often forgets to take his medications or takes them improperly. Insurance has no use for home visits.

He slips. He has difficulties. The secondary job is history. The primary job lays him off. He’s now totally on the HMO. They say he’s ok free living. He has slips and fall. He’s ok free living. He forgets his medications. He’s ok free living. He asks for assist but they say he’s not elegible on this cheaper chicken HMO insurance.

He died yesterday. Now the HMO is off the hook. No more insurance payments. No doctor visits. No Gene. Seems like a good system. Death by insurance.

Lest you think this is an isolated incident -

Two years ago a friend of mine, a retailer, sucessful in business but a small retailer, began to have urinary tract pain. He had no health insurance because at more than 1500$ a month it was more than he could afford. Additionally, that amount was for catastrophic insurance, you see, as a child he’d had bladder problems and every insurance company pro-rated him.  Finally he gets insurance. He’s had, what he thinks, is a bladder infection. Its been so severe that occasionally he sleeps in a bath tub with warm waters.  Small catch. There’s a 90 day waiting period.

He goes to his doctor who, as he’d suspected, sends him to urology. They want to examine his bladder and because of prior difficulties with anatomy need to do this in a hospital. There’s this 90 day thing. We wait. He’s more comfortable but of course not better.

The bell rings. Its a bladder tumor. They biopsy – perhaps benign, although most are not. It is benign it seems. But theres a second troubling spot next to it. Not benign. The tumor is resected, he starts chemo and radiation and everyone is hopeful. There are all sorts of limits to this insurance policy he has – so greater exploration, whole body films and the like, aren’t done.

Two months forward, he’s a bit dizzy and falls. There is an ominous cracking sound in his neck. There’s a baseball sized tumor there. Now we do more work up. Its a metatastasis. Alas it was a death knell. When removed and the neck repaired a shower of tumors widely spread show up.  After an enormous fight he choses to let go.

No more store. No more employees. No more friend. These tumors when seen early are frequently non-fatal. With time the outcomes are more dire.

Death by insurance.