tinkll1 (tinkll1) wrote,

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Why All the Fuss with the Bureaucracy? - Share Ourselves Clinic

Once a month, for the last 10 or more years, I've spent a morning in Costa Mesa at Share Ourselves Clinic. I see from 6 to 8 patients as a renal consultant, in a clinic that provides its services free through a cooperative arrangement with Hoag Hospital Presbyterian in Newport Beach. The clinic supplies chronic care to patients discharged from the hospital who can't afford to see community physicians because they lack even the most basic insurance, Medical Services to the Indigent (MSI) MSI provides the patient with a very basic drug formulary and the ability to perform laboratory tests. Further up the continuum of benefits is MediCal known in Orange County, as CalOptima. CO has about eight HMO's and a system of referrals and prior authorizations that were rationalized as attempts at cost control. I participate with a large percentage of these groups and they constitute the main referral sources for my nephrology practice. The CalOptima patients have access to most of what they need but the process involves the willingness of medical practitioners and their office staffs to try to navigate the obstacle course that the bureaucracy represents, and to do this for less than the prevailing remuneration that is offered for the care of Medicare patients, and those treasured and rare private patients.

The Community Clinics present a setting with staffing that provides a certain standard of medical care, and the physician volunteers are not paid, but enjoy the participation of a paid staff of nurses, aids, pharmacists and social workers. The patient population that I see at SOS is almost entirely Hispanic. 90% can speak only Spanish, and 90% are undocumented. As undocumented, they are not eligible for any insurance program, and must depend on a few community clinics or their own resources for the costs of health care.

My seventh patient, last Wednesday, was a 42 year old Mexican man who had been released from the hospital where he was admitted for diabetes out of control, swelling in his feet. He saw me for a renal evaluation. He had problems with his vision. He was on a long acting insulin, but he had no home glucose monitor (HGM). His HgbA1c was 11.2 (Good control with diabetes and renal disease = <6.5 To achieve this kind of control it takes education about diet, the ability to buy the right food and prepare it, at least 2 kinds of insulin, at least 4 checks of blood sugar per day, and thus a monitor, lancets and refill strips for HGM. Then the patient needs followup. We know exactly how to treat this condition. This is not cancer looking for a cure. This is diabetes in the 21st century in a country that spends a higher proportion of its GNP on health care and gets mediocre results. For this man, suboptimal care comes first from a strained budget where the clinic staff, to save money, to keep going, has decided to not supply the HGM machines, strips and lancets to its diabetics! Too expensive. So every 3 months I see patients like this with elevated HgbA1c's rapidly heading down the road to renal failure, with substandard care. They fall through the cracks. The long acting insulin keeps them out of hospital ER's until their infected limbs, congestive heart failure, or uremia, brings them back into the system.

If they have renal failure and need dialysis, we ride to their aid and give them "Emergency" MediCal They get dialysis. Their life is extended. Some people are happy. I am not!

These people need adequate care before they get to dialysis. They need education, supplies and care, and they need to enter the health care system instead of being treated as outcasts. The political problem of illegal immigration is one thing. When the person is sick, the politics just don't matter. The US military provided and continues to provide medical care to its enemies who have been taken prisoner. We don't provide health care to the gardeners and construction workers and food preparers who serve us and make our lives easier, every day.

And we establish parallel bureaucracies in the private health industry that construct ever more difficult obstacle courses for patient and professional to negotiate, and they advertise and honor their executives with six figure incomes for figuring out newer and better ways to limit life saving procedures and life saving drugs.

That's the bureaucracy that I am engaging in the phosphate binder battle. One small engagement in an ongoing battle in the health care industry.

We are a tired and ailing group, doctors. We cling to the notion that we are a profession, but we are now, providers so 41 years of experience and 9 years of medical training before that, props me up against a hearing officer, undoubtedly a lawyer, who will look for the wording that allows CalOptima to not permit me to use my professional judgment to select a medication that will statistically extend my patient's life by a year, or more! What do I know? I'm only a doctor, and if I were any good, I'd be playing golf and selling vitamins.

This is an argument for Universal Single Payer Health Care, and treating people who are sick, not citizens who are sick and insured. And giving doctors back that old concept that caught their eye when they were growing up, naive, in a promising post world war II society, where anything was possible, and providers were not yet invented.
Tags: health care, medicine as a profession, rants, single payer health care
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