American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, September 11, 2013

LIfe at Grady: All about the Benjamins

We have one of the amazing hospital pharmacists at Grady Hospital. She is smart and diligent and empathic and generous with her knowledge. I stopped in her office today along with one of the residents because I needed her help.

The question wasn’t about the pharmacokinetics of some drug or even about some kind of drug-drug interaction. Nope. This was a question about what is, unfortunately, one of the most common things that gets discussed at public hospitals: Cost.

Grady Hospital--and the handful of other safety-net hospitals in the U.S. that turn no one away due to limited ability to pay--has programs in place specifically for our poorest patients. That is, if you are at 200% of the U.S. poverty line or below, you qualify for a significant amount of assistance with whatever it is you need. And that is a wonderful thing.

Now, if you are like me, you probably have no idea what 200% of the federal poverty level is. And maybe you are one of those people who just walks around with that kind of information in your head, but I’m not. So I had to look it up today. And I’ll tell you why.

I had a patient sitting in front of me in a work uniform. He had worked some crazy oddball shift in order to get out in time to make this appointment with us for management of high blood pressure and diabetes. And really, this patient was super-motivated, kept appointments, and went through great effort to make it over to see us.

So we checked the lab results from the most recent blood draw and things looked horrible. The blood sugars were out of whack and the patient was clearly not doing what we asked at the last visit. And so we asked the patient straight up:

“What’s up with your blood sugars? Is everything okay?”

“No,” our patient replied, “I only take my insulin here and there because I can’t afford it. I can’t afford the blood pressure pills, neither.”

And that was weird because this patient wasn’t new to us. I mean, this patient had been coming to Grady in that same work uniform for many years. Why was this suddenly an issue?

My resident blurted out a question before I could. “Don’t you have a Grady card?”

What she was speaking about was the sliding scale card given to patients with limited ability to pay. The patient gave a hard head shake.

“I used to. But my job gave me just a little bit more money so now I don’t qualify no more.”

And let me tell you. This patient was a hard worker, and that uniform is not one worn by a person who makes stacks and stacks of money. And so we talked about it and the patient said, “Essentially, I am now just over the line.” Which was later clarified to be 201% of the federal poverty level. I agreed to look into what we could do to assist by talking to Kristi and our social worker.

I also looked to see what it all meant in concrete language. It turns out that $22,980 is the 200% marker for a single person and $31,020 for a two-person household. Yeah. So my (single) patient was making like $24K per year, up from like $22,500. And you know what? That patient was working hard for that little bit of money. Hard.

And so. I talked to all of the people that you talk to about these kinds of things and heard the same answers. Which essentially is that in order for us to help those who need it most, we have to draw the line in the sand somewhere. Unfortunately, our patient landed right on the wrong side of this and pretty much, there wasn’t much we could do to help in the way the patient wanted.

And so. I stood in front of Kristi’s desk talking about all of this and picking her brain about what to do. And she was at least able to locate some patient assistance programs on the blood pressure meds and lists of a few medications at pharmacies with fixed prices. But then we talked about the diabetic supplies that the patient would need for things like testing blood sugars and injecting insulin.

Even with a special coupon, all of the supplies would run close to $100 dollars per month. $100. A straight-up Benjamin Franklin one hundred dollar bill. Seriously? How in the HELL is this patient supposed to come up off of that much money for that AND eat? How.

$100 is a lot of money. Especially for some strips and some syringes. So how do you blame somebody for doing rock, paper, scissors when it comes to something like this?

Answer: You can’t.

So the very, very best we could do was this:
• Patient assistance meds through a pharmaceutical company
• Medications off of the “four dollar list” at Walmart and similar places.
• A suggestion for the least-expensive testing supplies based upon our research.

And you know? It was still dear (in price,) as my mom says.

I guess I just want to shine a light on the everyday struggles of people who are out here slugging it out and trying to make it happen. And how many things stand in the way of them going to their full potential.

“I asked for them to keep my salary where it was,” the patient said, “but they won’t do it. When you been there a certain amount of time, they got to raise you up some.”

“Seem like you better off quitting and getting disability,” the patient added.

Which broke my heart even more because, in this instance, it almost was completely true.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.


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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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