Thursday, November 20, 2008

Paying for labs

Last month, we received news at my clinic from "the bosses" that we were to use only one particular lab company for all our labs except for a few types of private insurance. This news came as a surprise, and the medical providers had not been asked for any input on choosing the company. I was very disappointed, as the one that was chosen just happened to be one of the slowest in processing times. When I questioned the administration about the decision, I was told that they offered our organization the best prices for our uninsured patients. End of discussion. Since there was nothing I could do to change the decision, I tried to improve the speed of processing through our customer service representative. Needless to say, nothing has changed on that front either.

So, I went about my business, grateful each time when I had a patient who had the kind of insurance which allowed us to use a different company. But, then, last week, bammm!!! out of the blue, another dictum. This lab company who had contracted to take on the organization's uninsured patients decided that they were losing too much money on us; understandably, they cannot do thousands of labs for free. And our organization decided that we cannot keep losing money by writing off the bad debt. Keep in mind that we are a group of federally-funded community health centers (CHCs), so we provide healthcare for any and all, regardless of insurance status. The policy on labs now has changed, and our patients who don't have health insurance have to pay cash up front for labs. As a provider, I do have the ability to say that a particular lab must be done, regardless of the ability of the patient to pay. However, someone from my staff has to inform the family of the cost of the lab, ask if they can afford to pay, then let me know if they can or can't, and then I need to note in several different places whether the lab is critical or not. I already try not to do unneccesary labs on my patients since for most kids a blood draw is very frightening, so when I order a test, it is generally very important! I suppose I am disappointed because I chose to work for a CHC so that I could provide care to all. I already have to choose medications by whether they are covered or not by each particular Medicaid program, I often have to get prior authorizations for medications and radiologic procedures!

I am very bothered and saddened by this new policy. Many of the families in this community are already struggling to make ends meet. My worry is that they will stop coming in when word gets out about this policy. Fortunately, most of the children I see are covered by Medicaid, but there is a fairly large population of adults who can't afford health insurance. I also understand that our organization cannot continue to provide essentially free care indefinitely. The patients know that we do not send out bill collectors, and some of them have large unpaid bills. However, if they can come in for preventive healthcare, which sometimes includes labs like lipid panels, we end up saving money on them in the long term. I really don't know what the solution is, except that we need to address the healthcare crisis immediately.

Along those lines, I happened to come across the blog of the country doc, Dr. Cohen, discussing President-Elect Obama's choice of Tom Daschle for head of the Department of Health and Human Services, which seemed quite relevant to me, as I continue to struggle with this new policy. I admire Mr. Daschle, but like Dr. Cohen, I am concerned that he may not truly understand what is going on the ground level of healthcare. Both Mr. Daschle and his wife have ties to healthcare firms. Now, I know that healthcare firms are not inherently evil, but they are businesses which want to make money. I'm also not against making money, but I think that sacrifices will have to be made on everyone's part. I am simply hoping that Mr. Daschle will seek input from all participants in our broken healthcare system, including families, primary care physicians, specialists, pharmaceutical companies, and health insurance companies. We need a comprehensive team approach if reform is going to succeed. As a country, we have a lot on our plate right now, and I frankly don't envy Mr. Obama's position one tiny bit!

Friday, November 14, 2008

Brain Power

When I was eleven years old, one of my cousins had an aneurysm which left him a quadriplegic. He had been in medical school, was an avid mountain climber, and an outstanding violist. He had had some non-specific neck pain for a couple of days, and one night, it was bad enough that his mother took him to the hospital. The short story is that he went to the operating room with the hopes that the aneurysm could be repaired but woke up paralyzed, on a ventilator. This really impressed me, as he could speak, but he had to use a computer to write, using his tongue to move a cursor. Ever since then, I have been afraid of a similar thing happening to me, especially after learning about multiple sclerosis (MS) and amyotrophic lateral sclerosis (ALS) a few years later. Of course, when I was a first year medical student, I had every disease we learned about, including MS and ALS! Fortunately, I survived intact.

For those of you who may not know what ALS is, it is a rapidly progressive and always fatal disease which attacks the nerve cells that control voluntary motor function. Eventually, the upper motor neurons (those in the brain) and the lower motor neurons (those in the spinal cord) stop working, so messages do not get transmitted to muscles, and the muscles eventually shrink and waste away. Oddly enough, most patients retain control of bladder and bowel function, eye muscles, and the senses of smell, taste, hearing, and touch. Usually patients die within three to five years from the onset of the diagnosis, although approximately ten percent live for ten or more years. For more information, I found the website from the National Institute of Neurological Disorders and Stroke to be very informative.

These memories of worrying about various illnesses came back to me last week when I watched the CBS news show, Sixty Minutes. There was a segment called, "Behind the Scenes: Brain Power" ( which just blew me away. It focused on a neuroscientist by the name of Scott Mackler from the University of Pennsylvania. He was diagnosed with ALS, and the disease has progressed to where he is ventilator-dependent and unable to speak. However, he is now able to communicate using Brain Computer Interface Technology, which basically allows a person's brain to be connected to a computer using EEG electrodes attached to a cap which is placed on his skull. So, in order to write a letter or to speak, Dr. Mackler looks at a computer screen with flashing letters, and the computer writes the letter that he is thinking of. Absolutely amazing!! The neuroscientist who was "locked in" by his disease now can write journal articles and goes to work in his lab where he conducts research. The story also talks about a woman, Cathy, who suffered a brain stem stroke which left her only able to move her eyes and with some facial expression. She volunteered to participate in a clinical trial where the Braingate system was implanted directly into the motor cortex of her brain. Cathy is able to move a cursor on a computer screen by thinking about how she would move her hand; she is able to turn off lights, for example, using this technology.

Advances in the science like this are always so exciting to me. Yes, I'm a nerd, I know. But the potential for this Braingate technology is limitless, and there are so many people who could benefit from this. Obviously, it would be even better if we could find the causes of neurodegenerative diseases so that we could prevent them, but even if we did, it could be used for stroke victims, accident victims, and many others. I am concerned that with our healthcare system in shambles, along with our economy, that funding for research will be cut, but I hope that our amazing, creative, dedicated science community can continue to thrive somehow.

Friday, November 7, 2008

I'm back! It's been a busy few weeks since I last wrote, between an onslaught of strep throat infections at work and the election, I'm utterly exhausted! Even though the election was decided fairly early on Tuesday evening, I was up too late because I was too stirred up to go to sleep. I was so excited but also apprehensive about our future as a country. Anyway, I'll stop talking about the election, since I have no new and/or amazing insight to add to all the discussion, except that I am very proud of the people of the United States.

On a completely different note, I had a patient this week that reminded me of Stuart from MadTV. For those of you who don't know what I'm talking about, here it is:

My patient was a little younger, fortunately, and I was not thrown out of the window, only because we don't have windows in our exam rooms. But his mother just stood there and watched, then reinforced his behavior by comforting him. She then proceeded to threaten him with a shot if he wasn't good, asking me to back her up on that!! The boy had already dismantled the exam room and managed to pull down almost all the stickers off of our sticker boxes...all this within the first few minutes before I even walked in. The first thing he did, actually, when he arrived at my office, was set off the fire alarm in the patient bathroom. As soon as the alarm went off, I knew he had arrived - it's one of his favorite things to do!

This boy can be well-behaved, I've seen it. When he comes in with his grandmother, he's fine. We've come to an agreement with the physical exam: he holds the stethoscope for me on his chest, I hold it when I listen to his lungs; he holds the otoscope with my hand on his, same goes for the ophthalmoscope. So, needless to say, when I see how he behaves with his mother, it frustrates me. When I ask her about it, she explains to me that his feelings get hurt when she disciplines him, so she's given up. I offered her a session with our social worker to help her understand how she can be her son's friend but also his mother...she was interested, now we just have to see if she shows up; until then, I can only hope that he comes with his grandmother!

We all have our Stuarts, be they children or adults. Sometimes we can work with them, sometimes we can't. They can be difficult to examine, and I always worry about missing something, a murmur for example, when I have one of these wild screaming ones. But, when I'm ready to pull my hair out, I just think about Stuart, and I start to laugh, and think, in his voice, "I can do it...."