Laurence Lewin, M.D.
1310 W. Stewart Drive
Orange, CA 92868
Nephrology and Internal Medicine
Tel. (714) 288-9229 Fax. (714) 288-9315
March 24, 2008
The Honorable Arnold Schwarzenegger
Governor of the State of California
State Capitol Building
Sacramento, CA 95814
Dear Governor Schwarzenegger,
I am writing to you as a physician who has practiced nephrology (treating patients with kidney disease) in Orange County since 1967 and shares your concern with the economical usage of medical resources. I am proud to be both a member of a profession that is focused on saving lives and mitigating the effects of illness, and a Californian. As I serve an economically disadvantaged community with many unable to afford health care, and volunteer at Clinica La Amistad de San Jose and Share Ourselves Clinic, I am familiar with the gallant design of providing the essentials of life saving care to those who would die without the intercession of the State, through its MediCal program, and Orange County, through its Medical Services to the Indigent. The needs are immense and the program ideals are constantly stressed by the realities of fiscal constraint.
Nevertheless, in 41 years of private medical practice, I have never had to turn an indigent patient away from hemodialysis treatments that are life saving. Even before Medicare embraced End Stage Renal Disease, the State of California was funding the care of indigents who would die without this access.
Of course, the providers of this care have an obligation to minimize the expense to the state wherever possible, without compromising patient care. I am writing to you because I believe that it is possible to initiate very significant cost saving procedures that will streamline care, satisfy the financial security of dialysis firms and provide for shorter hospital stays and greater efficiency in the use of personnel.
First, let me review a typical case history:
A 70 year old Hispanic Female, undocumented, living with a large family, unable to afford medical care, is brought to a hospital emergency room with diabetes out of control, swelling all over her body and is admitted, stabilized and treated in the hospital, during which she is discovered to have lost 90% of her kidney function. A dialysis access is placed, but with further stabilization, she recovers a further 5% of her kidney function and dialysis is not felt to be necessary. After a great deal of effort, including many applications for disability, PRUCOL, she is referred to a neighborhood clinic, with records and a treatment plan. The clinic is UCI Family Practice and this complicated patient is managed at the facility until, 2 months later, she is again hospitalized through the emergency room, fortunately encountering the same physician, and again the paper work is processed and the patient referred back to the clinic, relatively stable, still not requiring dialysis but requiring intensive followup.
One month later, she is admitted to the hospital with diabetes out of control, fluid overload, and congestive heart failure. Her breathing improves but kidney function deteriorates and, in light of her increasing frequency of hospital admissions, and of the decreasing intervals between them, a decision is made to start dialysis.
The same forms are filled out, again. The patient is ready for discharge, but no dialysis clinic will take the patient. They want a MediCal application number. This process, if initiated on a weekday, might take 3-5 days, during which the patient sits in the hospital @ $2,000-3,000 per day, until a number is received.
This is not an isolated case. It happens again and again. It has happened to me at least 3 times in the last year.
1) Fast track the application process and generate the number the same day. This saves a minimum of $10,000.
2) Create an ombudsman’s office. This can simply be a person on call, including weekends, to provide effective communication between health care personnel that recognize the problem, and an individual within the state bureaucracy who can assist the fast track. This will pay for itself in the first week of its operation, and it will do wonders for the morale of health care personnel who are frustrated with bureaucracy, work 24 hours a day on behalf of their patients, and can’t understand why common sense can’t be applied in the same fashion to cut through the red tape.
There are many ways that better health care can be provided while actually saving money, but innovation and streamlining runs up against entrenched bureaucracy, and people need to be motivated. I have tried this on lower levels, working up through the bureaucracy but the pace is glacial and motivation is lacking. The bureaucrats simply outlast the innovators, who shrug and accept the status quo.
That’s why I’m writing to you, Governor. To get something done, and save a little money that might go into providing necessary medicines for the diabetics so that their disease might be treated before the taxpayers ride to the rescue with hemodialysis.
P.S. There are many places where intervention might prevent the hospitalizations of this patient, but I’m not asking you to inaugurate Universal Medical Care, just make the existing program work more efficiently to conserve the health care dollars. I feel that this is within the realm of administration, and thus under your level of responsibility, but I will forward a copy of this letter to members of the legislature who may have the power to accelerate its recommendations.
In this day of grandiosity, I envision moving onward to the newspapers if this constructive suggestion is ignored. Who knows, maybe politicians and bureaucrats may actually do something in the public interest simply by being urged by an earnest constituent, and not by a professional lobbyist.