And yet, there are some shining exceptions, where altruism wins out, when the right thing is done, just because it's the right thing. Many of those decisions were made years ago, when a Democratic administration brought in Medicare, against the wishes of the American Medical Association and most of America's physicians. They didn't want that "socialized medicine," that is the National Health Service in Britain, or the Canadian health care system. They didn't want the government coming between them, their profession, and their patients.
That was long before the for profit Health Maintenance Organization, the insurance industry and Big Pharma, with the emergence of "marketing" for the now, renamed, providers, created a climate of rationing for profit, cost shifting, and cost containment. Now clerks, reading from an algorithm, decide whether a patient is anemic enough to get erythropoetin. That is, if the provider submits the right form, and it gets to the right place, without being rejected because the information is incomplete. The rationers can't trust the ethical professional, because he has lost his cloak of ethics, and has become a largely interchangeable provider, plugged in like a worker on an assembly line. Physicians no longer have practices. They serve at the discretion of an HMO which rates their cost effectiveness, their willingness to work for the least possible payment content in knowing that each year, their contract with an employer may shift their insured to another group, where the consumer of health care, .... we call them, our patients... moves on to begin with a new physician, better or worse than the previous one, but different.
Variety, the spice of life.
That's the background.
Well, even before Medicare was passed in the 60's, and in 1973, adopted End Stage Renal Disease as the only disease entity that qualifies an individual for Medicare even when they are not totally disabled, or over age 65, the great State of California decided, perhaps by passivity, but nevertheless, allowed patients with ESRD to get dialyzed under MediCal, California's version of Medicaid, the State and Federal collaborative health care program for the impoverished. At a cost of $25,000 to $50,000 a year for hemodialysis, it doesn't take long to be impoverished, if you are uninsured.
At first, the problem was there wasn't enough machines, nurse and nephrologists, but there was funding from the state, while the private insurance industry sought to keep the procedure in the definition of "experimental therapy," and therefore, not their fiscal responsibility. Medicare changed that, completely.
A great Golden Star for the Golden State was the decision early on, that MediCal would pay for anyone, any human being, with ESRD who needed dialysis. It was kind of like the law of the sea where fellow seamen feel the responsibility to rescue the drowning and don't throw them back if they happen to speak another language or are of a different religion. Specifically, in the border regions of our state, and others, this was a boon to undocumented Mexicans, those people who pick our vegetables, wash our cars, cut our grass, buss our dishes, clean our houses and raise their children to be good American citizens. The economy of Southern California would be threatened if they disappeared. And, in 1967, they were treated like the rest of the human beings who develop ESRD in California, and they got MediCal benefits if they required hemodialysis or if they were pregnant and needed maternal or child care. There was a lot of grumbling. There still is a lot of grumbling, but we still dialyze any one who needs it. And I am extremely proud and fortunate to be a part of the process.
How the state defines "Emergency Care" is another issue, and the full MediCal formulary is not available to Emergency MediCal patients, who must do with fewer medicines, and for whom, no exceptions are made in CPAS requests (justifications for non-formulary drugs.)
This leads to the paradoxical situation of not being able to provide effective phosphorus binders, antihypertensives, and many other drugs to these second class non-citizens. ESRD is treated with dialysis, but secondary hyperparathyroidism, rampant atherosclerosis goes untreated until the emergency arrives. When the person falls off the roof, the safety net just isn't there, and when he is tottering on the edge, the inevitable fall is ignored until the sickening crunch when he strikes the ground, and the emergency is evident. It would be as though the Coast Guard rescues the drowning seaman, pulls him on board, gives him a good meal and a life preserver, and throws him back into the ocean 50 miles from shore.
Of course, this is an exaggeration! There is an exception called PRUCOL that permits one to apply for regular benefits. In other words, the undocumented patient, having no place to get dialysis in Mexico, is granted the state of regular MediCal, and access to the full benefits of citizens of our state. But, there is a process, and a path, and no ombudsman, and an underfunded, overworked staff, and stuff happens. It happens again and again, and because of its inefficiency, it keeps happening and it costs me and the other taxpayers a lot of money. No one seems to give a damn!
I am not talking about one case, I'm talking about 4 or 5 a year at least in most nephrologist's practices at a waste of millions of dollars while these patients go through the process of getting the eventual approval. A week at $2,000 a day, sitting in a hospital room, until the state says, yes, like the thousands before him, this individual does qualify for ESRD and can be diayzed in a clinic at a cost of closer to $750 per week. Or yes, a medicine that costs $5 a day, but is not in the formulary, can be used as an outpatient therapy, and does change the blood pressure from 220/130 to 135/70. Again and again and again!
Well, Arnold is going to fix things. He is just going to start in a different place. Here's what I got in the mail, while I was trying to get a patient out of the hospital who needed a dietary supplement following a hemigastrectomy and minoxidil for accelerated hypertension. He eats about 450 calories a day before he begins to vomit and can't hold anything more in. This is going to mean total parenteral alimentation or jejunostomy feedings, and they can only happen in the hospital, where the emergency is recognized.
This was a mailing to perhaps 20,000 physicians, maybe 50,000 letters, I'm not sure how many, at maybe $0.37 for the stamps, or maybe they get a special rate. Perhaps this deficit hawk will find the funds for his warning letter by temporarily withdrawing anti-convulsant drugs from epileptics, or skipping some vaccinations. With all that's ailing health care, Arnold focuses on erectile dysfunction therapy in convicted sex offenders. Perhaps he will be the next budget czar for the defense department who allocates a significant portion of the budget for a Star Wars defense while leaving the cargo containers unchecked! What do you think?