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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