One expensive patient can prevent treating a dozen others

For most of our patients, the student run homeless clinic is the last stop in a long, fruitless search for healthcare in the city of New Orleans. Recently, an insulin-dependent diabetic came in who had his insulin pump stolen, an unfortunate side-effect of homelessness. The physician prescribed a 150 dollar-per-month supply of insulin—far out of our price range—not knowing how much insulin costs. This was in addition to a sixty-dollar albuterol inhaler for his COPD and lisinopril-HCTZ for hypertension.

As the pharmacy director, I was placed in the unusual position of vetoing the prescription. How do I explain our inability to prescribe medicines to a patient who acutely needs them? Or explain our limitations to a doctor who rarely thinks about them? How do I justify not treating a patient to my own conscience?

I took the patient aside, and we tried to work through his options. We explored and applied for patient assistance programs that pharmaceutical companies run for disadvantaged patients. But for a patient who had neither a permanent address nor a phone, the paperwork proved complex. He doubted he would hear back from them. I referred him to the two other homeless clinics around the city, but I knew that funding for those had dried up so remarkably during the recession that they probably closed down or denied new patients.

Even if they offered his insulin, one of the clinics was not on a bus route so he had no way of getting there. Finally, I made a referral to the public hospital. For a non-referred patient, the hospital is so overwhelmingly crowded that an appointment can take up to three months. Even using our accelerated referral process, the next available appointment with primary care was in a six weeks. It was a frustrating and disheartening experience to find that every avenue was so clogged with administrative red-tape that it was unlikely he would receive help in the near future.

Much to my chagrin, we still could not write him a prescription for his insulin. After meeting with him, it became obvious why so many homeless individuals are caught in a crippling cycle between the emergency department and vagrancy.

I remain optimistic because at the clinic, we make the best of our situation. With an average annual budget of 25,000 dollars, mostly through private donations, we have over 700 patient visits in a given year. We do this using volunteer physicians and students, an approach based empiric-therapy and a fast-track referral system into the public hospital for complex or very sick patients. But for many, we manage chronic conditions with simple measures.

We have an in-house dispensary, for which we purchase commonly prescribed generics in bulk—antibiotics, allergy medicines, diuretics, and NSAIDs, among many others. We also have an account at a local pharmacy, where patients can fill out reasonably price prescriptions for free. For the vast majority of patients, we can come up with a treatment plan that accounts for the short- and long-term management of disease with frugality.

But patients such as these have forced me to think deeply about medicine in a way that seems to contradict my medical training. We are taught that our number one priority is as our patient’s advocate. On the other hand, as the pharmacy director, I am forced to constantly consider that one expensive patient can prevent us from treating a dozen others. Patients thank us for our work every clinic, but for those whom we can’t accommodate, I am left wondering what else is there to do?

Amol Sura is a medical student.

One expensive patient can prevent treating a dozen othersThis post originally appeared on the Costs of Care Blog. Costs of Care is a 501c3 nonprofit that is transforming American healthcare delivery by empowering patients and their caregivers to deflate medical bills. Follow us on Twitter @costsofcare.

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  • Dr. Drake Ramoray

    I think you might need to take a second look at your formulary plans for patients with diabetes. Assuming the diabetic patient in this article isn’t using large volumes of insulin and has type I diabetes (Why would a homeless guy with type II diabetes be on an insulin pump and/or not on oral meds?). You can get a bottle of NPH, Regular, or 70/30 at the much maligned Walmart for about $15. That 70/30 in a lean type I diabetic would probably last a month (give or take). If type II some generic Metformin if tolerated and the above insulin would go along way as well. Is it optimal, no. Before 2000 it was a pretty common regimen though.

    • querywoman

      Dr. Drake, I posted about the same time as you as a former welfare worker. The theft risk is very high for an insulin pump, and I’m not sure what they look like. Also the loss risk!

      • Dr. Drake Ramoray

        Off the shelf, no insurance an insulin pump costs about $10,000. Pump supplies are hundreds of dollars a month. It makes no sense for this guy to be on a pump at all even if he has Type I diabetes. There are way cheaper ways to get insulin in people.

        I just googled it. Relion (regular, 70/30, NPH) 24.88 per bottle at Walmart. Perhaps the formulary at the free clinic could use this option as they appear to have some existing programs.

        • querywoman

          The cost is astonishing and much too costly an item to be on a homeless person! I like your idea of the Reli-On, much as I hate Wal-Mart. The free clinics are often governed by rules that specific what they can get. The brand people want the business. However, I find church and community clinics more flexible than government clinics! I hate it when the public hospital districts get overly involved in the private charity clinics.
          Perhaps the clinic should work out a deal with Wal-Mart to buy insulin from them.
          If the guy really needs a pump, and he’s responsible enough, he needs to be in a more settled living situation.

        • _userM9801

          One $10,000 pump would have bought him 400 months (33+ years) worth of Relion (regular, 70/30, NPH) at Walmart. Just to put things into perspective.

          • querywoman

            When I took insulin by needle, twice a day or more, I managed myself fairly well. No one ever mentioned a pump. I’m on Victoza pens now.
            My experience in welfare and on Victoza with the pen tips makes me like the idea of insulin pens with pen tips better for the homeless.
            The needles take up too much space and are tempting to the druggies. Another idea would be for the clinic giving him maybe a 3 week supply of needles and coming back for them
            Many diabetes will need more than $100 in meds per month. Is this clinic the best place for them?
            The problem with the drug program is also that he needs his insulin now! If he gave up on the paperwork process, that’s common among the needy. Does the clinic have a good social worker? Could the drug program send his insulin to the clinic?
            In my county hospital system, I learned that the words, “Patient needs to be seen as possible,” work better than, “Patient needs next available appointment.”
            Our county default system for a patient who needs a life-maintaining drug like insulin immediately is to go a day walk-in appointment at the hospital clinic or go to the emergency room at night. The patient will be seen and provided with enough insulin to last them until a clinic appointment.
            The other option, like I said before, is to see if the Wal-Mart Reli-On would cover a month inexpensively. Then, a charity might could cut a check to Wal-Mart for his medicine. But, you need to already have an option in place for when he runs out of medicine.

            Is the prescribing doctor new to the clinic? Dr. Drake uses the term, “formulary.” I wonder if the prescribing doctor needs to understand more about how to prescribe appropriately for a homeless person with a high risk of theft and loss.
            I do not like to keep a lot of insulin in my own home. What if I had a fire? Yes, I have renter’s insurance, but the claim process can take a while.

  • querywoman

    I was a welfare worker for years. He should be able to get what’s derided as an Obamaphone, a free cell phone with a certain amount of minutes per month. That will get stolen also! Many homeless centers used to have free voicemail services for the homeless. I really hope the free cell phones have not replaced them, because of the risk of theft. Shelters allow clients to use their addresses for mail. But, this may not be good enough for a drug company. I prefer the voicemail option at a mysterious electronic location for non-theft.

    I used insulin for years, but wasn’t on a pump. So I’m asking why is a homeless person on a pump? The theft risk seems very high! But that’s a medical issue that I wouldn’t understand. Needles require a lot of storage and also have a VERY significant theft risk. How about an insulin pen with disposable needle tips?
    The best option where I love would be to send the client to the ER at the public hospital. They would surely give him a limited amount of insulin supplies and expedited clinic referrals. The public hospital staff answering the phone during the week may not explain this to you. I know not to believe what the public hospital clerical staff says. This is the kind of thing that your patient has to try and see what happens.
    Some church or nonprofit hospitals would see him in emergency also, but they will run into the same problem as you: a limited supply of expensive drugs and having to go through the pharmacy programs.
    Some charities, the kinds with food banks, clothes, and limited money for housing assistance, might be able to write a check for some prescriptions.

  • Gregory Dursteler

    Sadly this person’s best option may just be to get arrested. In prison he’ll get shelter, food, and the medical care he needs. Of course, that does reflect pretty poorly on our society.

    • querywoman

      Remember the guy who stole a buck so he could get health care? There were community clinic options for him!

    • Guest

      Under Obamacare, every American – including this dude – will have health insurance. On a low income – like his – , it will be provided free (courtesy of taxpayers). Problem solved!

      Think of all the charity clinics that are about to go out of business!

      • querywoman

        The charity clinic is a type of insurance now. I figure the money will be just redirected somehow! The charity clinic will get paid differently. Logistical quagmire! The British and Canadian systems don’t have all this confusion.

        • Disqus_37216b4O

          “The charity clinic is a type of insurance now.”

          It’s funded by its clients? Really?

          Do you have any idea what “insurance” means?

          • querywoman

            Yes, I know the difference in insurance and these community clinics. George W. Bush liked the community clinic concept so they grew under him.
            The clinic is probably funded out of some kind of government funds and maybe private contributions, not what we think of as “insurance.”
            Obamacare will probably put most of these “uninsured” patients on Medicaid. Then these clinics will surely sign up to receive Medicaid for each individual patient. They should also be able to stock the pharmacy better, getting Medicaid drug money for the patients. Or, the patients can go to another pharmacy for meds.
            Medicaid is what we think of as “insurance.”
            But, here’s what will happen. Currently, a person has to “apply” for Medicaid with a state worker, an administrative process. The process could go automatic for Medicaid, though I sincerely doubt it.
            The medical people posting on this blog predict a shortage of primary care with Obamacare. Well, a lot of people like this homeless guy are already getting it.
            The source of funding for his care will change. This processs will add significant administrative expenses to the cost of implementing Obamacare. Do we have enough state workers now to do it? I say, fat chance!
            It will take years to level out the expense, etc., of Obamacare!
            As you all know, most doctors currently lose money on Medicaid. Most Medicaid patients are usually best served at public health sources associated with medical skills, where the doctors salaries are paid out of additional funds as well as Medicaid. And that’s why they can spend more time with Medicaid patients.
            I don’t predict that care for existing Medicaid patients will even change that much. They’ll keep going where they go already, and the medical schools still need patients to learn on!

          • Guest

            A very thoughtful comment. My greatest fear with the government taking more and more of workers’ money in taxes to “take care of the poor” is that fewer people will give to charities which used to fulfill those functions. Democrat or Republican, NO government does charity provision better or more efficiently than small local private or church run charities. But people are starting to think it’s the government’s job to collect and redistribute money, so when you ask for a donation to, say, buy a homeless person’s insulin, they say, “I already gave at the office – Obama’s taking care of that now!”.

          • querywoman

            If you are talking about me, I put in a lot of thoughts. I used to attend a large urban church while working in public welfare. I have done some outreach work through the church, and am familiar with government and religious missions.
            The religious missions can be more flexible than government. Government has to make rules. I know I put somewhere on her that I dislike it when public clinics get too involved in church clinics.
            You already pay plenty in taxes that are applied to various social programs. You pay state and local taxes, as well as the federal. There’s money somewhere already for his insulin.

          • Guest

            Yes, I was talking about you. I appreciate that you are able to offer interesting thoughts on matters like this from a perspective not a lot of people are able to tap into.

          • querywoman

            Like anyone, I get my share of dislikes. But, as a person who worked for the government 10 years, for a state agency and also a federal one, I observed patterns. Then throw in my knowledge of church outreach.
            Here’s how a lot of budget cuts work. Mental health is a great example. The feds cut mental health funding, and then the state and local governments have to pick up the cost. And then the state and local govmts b!tch at the feds about the expense, and the federal funding gets restored eventually!
            Republicans don’t necessarily oppose social programs; they just prefer block grants to the states.
            But, as I keep pointing out, the Affordable Care Act should shift a lot of the health care expense load from the state and local govmts. to the federal level! I predict nobody’s state and local taxes will go down!
            If you live in a county health district, like I do, ever year your county health district will want to raise your taxes due to, “government cuts.”

  • Molly_Rn

    The loss of Charity Hospital has had profound effects on Nawlins. My second thought is how pathetic this is in the “richest, most powerful country in the world”! Shame on all of us.

    • querywoman

      Did Charity Hospital go down with Hurricane Katrina? An unusual but perfectly natural event that will happen and effects medical care! It’s always easiest to function with what’s existing, like my own prediction that the free and community clinics, whatever they are called, will just find different ways to be paid under Obamacare.

      • Molly_Rn

        So how exactly do you think the doctors and nurses who work in these clinics get the money to eat or have a roof over their heads.

        • querywoman

          Usually from various government levels, like a lot of federal grants, and from private contributions. So, if a lot of the zero income to very low income patients get put on Medicaid, some of the payment source will shift.
          Medicaid is currently half federal and half state money.
          The clinics may also get some drugs free from the drug companies.
          Republicans, loosely, like to block grant money a lot and put in under local control instead of central control.

          • Molly_Rn

            I have worked for years in community and also Indian health clinics. The name of the law is the Affordable Care Act. You are using the derogatory name to put it down. This will probably shock you but i’m for Medicare for all, single payer via the government where you have the low overhead of a Medicare system instead of the for profit greedy bastards of the health insurance companies. I have Medicare and it is great. By the way it isn’t free. I pay my premiums to Medicare, but I actually get a great return on my money.

          • querywoman

            I would not have known the name of the act nor what is a derogatory term for it. Kindly inform me what the “derogatory” term is.
            Canada cause their own system, “Medicare.” Obamacare, good or bad, will clearly add layers of confusion.

          • Molly_Rn

            It is called the Affordable Care Act and republicans made fun or it and derided it by calling it Obama care, as if making healthcare available to Amercans was something to be ashamed of.

          • querywoman

            I hate the term, “Obamacare,” but didn’t know what the correct term is. Thank you.

          • querywoman

            Molly, you will surely agree with me that nothing is free. The clinics gets their funding somewhere. I used to attend a large urban church. I’ve know Christian doctors who volunteered at the charity clinics.
            Like on stay-at-home mom doctor who was married to an employed doctor. She volunteered at church clinics. Her time was a total donation. I view at that her employed husband also funded her time, and that was a form of giving for him.
            But, if one of those clinics has a full-time doc, he or she has to have a salary.

          • Molly_Rn

            As does the clinic manager and nurse manager because their jobs are full time. Bless the souls who work so hard to help those less fortunate than themselves.. I am an atheist and do our fair share of charity to but we are not an organized group.

    • querywoman

      I have just been researching Charity Hospital. In Texas, I used to use Entergy, a Lousiana company, for my electric bill. Not surprisingly, they pulled out shortly after Katrina and t’ferred me to someone else.
      So you are left with a huge flood-damaged med complex and tons of re-directed patients?

      • Molly_Rn

        Very sad, Charity had the busiest Emergency Department in the US and the people who worked there were fabulous. They provided real quality care to people who had no place else to go. Never thought in my lifetime that there would be no Charity.

        • querywoman

          I hope it’s not rebuilt in the same place, even if some of the levees, etc., have been upgraded!

          • Molly_Rn

            I think it is over for Charity. The poor don’t vote so those in power don’t give a s-it about them.

          • querywoman

            I’m a Christian, but most of those clinics get most of their funding from government sources, usually federal! When I worked in welfare, the clients would scream at us over their food stamps, etc., not realizing that the workers cared more about them than anyone else. We would have been happy to do more for them!
            In the years since I left, I have decided that food stamp recipients are the most-resented group of Americans.
            By throwing in Charity Hospital, we did a roundabout that got back to my argument that most of what we have, the community clinics, will continue to exist. The funding source will shift! Maybe it’s more correct to say Medicaid money will add to their funding!
            The free clinic mentioned in this article will probably notice the biggest change in the prescriptions they are able to provide, since they will get Medicaid reimbursement for each patient, if the patient applies and gets his or her Medicaid.
            I’m not a health professional, but health care is a never ending sinkhole. If every patients gets, say 3 scrips a month, they will just keep needing more and more!
            You never meet all the need in hunger or health care!

          • Molly_Rn

            That is the beauty of Medicare. We can use preventitive medicine to teach them how to stay well, exercise, eat properly, take their meds, and take care of themselves and keep them out of the hospital. It is cheaper to help keep people well by spending the time, energy and meds on prevention. Asthma for example can be controlled at a moderate cost and at an incredibly expensive cost in the hospital. If we are all in it together with everyone paying into the common pool with a low overhead like Medicare maintains than we all benefit.

          • querywoman

            Was off compter several hours. I have traditional Medicare, have had it for maybe 10 years. I never was eligible for Medicaid, but I certified pregnant women and children for it. The best medical care for current Medicaid clients is usually the medical school/public hospital combo, since private docs loose money on it. The medical schools and public hospitals pay their docs out of additional funds.
            I had private insurance related to jobs many years. Also had to rely on county health care for a while.
            I very much like my Medicare. Most of my docs just want my 20% after I meet my deductible. I have payment plans with the ones who don’t want my 20% up front. Very few hassles with it; referrals easy, etc.
            I also think doctors take my health problems more seriously now that I am on Medicare.
            Chatting with you made it fully hit this clinic is New Orleans. New Orleans especially cannot afford to have a single charity clinic close! The clinic will have to rely on other funding, which hopefully will continue, till they get more of their clientele on Medicaid.
            I assume if Charity Hospital had not been decimated, it might be easier to get an emergency supply of something like insulin!

          • Molly_Rn

            Yes, it would have been easier for the person to get the insulin they needed.

          • Guest

            Look up the definition of “charity”. Charity is given freely, prospective recipients don’t “vote” to receive it, the only ones “in power” of deciding who to give charity to are those in charge of the charities.

            Our church votes on which food banks and shelters to support with our tithes, for instance, but no one can “vote” to take part or all of our donations. If we decide for whatever reason to redirect our charity from one shelter to another, the residents of the first shelter can’t “vote” to force us to keep funding them.

            If something is taxpayer-funded, if the government is taking money from workers and handing it out to those they deem “more worthy” of that money, that’s not charity. That’s just income redistribution.

          • Molly_Rn

            Duh, Charity was a hospital in New Orleans. The hospital mainly served the poor and the homeless who don’t vote so the powers that be especially the republicans don’t give a crap about them. Before you comment you should know what you are talking about.

          • Guest

            So it shouldn’t be called “Charity” Hospital, it should be called “Welfare” Hospital.

          • Molly_Rn

            I have two words for you and they aren’t “let’s dance”.

          • Guest

            Did you know that there actually used to be TRUE charity hospitals, before the federal government stuck its nose in?

          • Molly_Rn

            Yes, I worked at one in Chicago that was supported by the patients who could pay and by donations. It was the medical insurance companies and managed care that killed it not the government. It was killed by the greed of private companies that killed a truly wonderful non-profit hospital.

          • querywoman

            Dear Guest, as for “TRUE charity hospitals,” both universities and medical centers used to be the domain of religious institutions. Religion gets an undeserved bad rap in the sciences for suppressing scientific development. The universities in Medieval Europe were places with science departments. Ditto for the Islamic institutions further south. Unfamiliar with Asian development!
            In the modern world, the universities and medical centers have shifted to government control.
            Medicaid is government welfare, in terms that a person like a baby who has never worked can be put on welfare. Somehow, from my past experience, food stamps aren’t exactly considered welfare, but I think they are. A person who has never worked can draw food stamps!
            We all know how both the universities and medical centers want more government money all the time. The universities sit on their ever-fattening endowments and make students pay with federal loans.
            Law and medical students prefer to go to state schools, because they will owe less! So the state law and medical schools have become better than the private, including the church, schools.
            Reading this blog, I think the real problem with American doctors starts now in the medical system, with the abusive student loan system. That’s what I call indentured servitude!
            Scottish Rite Hospital in Dallas used to provide totally free care to children with orthopedic needs, but someone paid for that. Donations, whatever! Now they have stated they will start accepting payment from other sources, but won’t turn anyone away.
            Most church-related community clinics get federal grants.

          • querywoman

            Molly, heh! Heh! “Charity” is just a name. It probably funded the way I’m familiar with county hospital districts in Texas in the larger counties. Was it part of a PARISH hospital district?
            I’ve seen a few doctors in Texas who did residencies at Charity Hospital. Did Charity underpay its residents? Most of them were greedy even if they had great skills!
            But that could have been my luck of the draw. A few bad apples don’t spoil the whole bunch!

    • M.K. Caloundra

      We won’t need “charity hospitals” any more. Under Obamacare, everyone will have health insurance.

      • Molly_Rn

        Nope, the homeless and others will still be uninsured. We didn’t get universal single payer insurance for all; we weren’t smart enough to demand it.

        • Guest

          “Nope, the homeless and others will still be uninsured.”

          It’s illegal not to be insured. They will be fined. Their insurance will be 100% free (paid for by working families), I’m not sure what more you want for them. Maybe we should PAY them to take the free insurance we’re providing for them?

        • querywoman

          As you know, I maintain that the homeless and other zero to very low income people will be added to Medicaid if they are not already eligible. Many uninsured people in the lower to middle-middle classes are already getting care through other public programs. I’m not sure how the Affordable Care Act will play out, but I don’t think there are penalties, or maybe not enough to encourage middle-middle income Americans they need to pay a monthly insurance premium, no matter how small.
          I think it will mostly affect the uninsured upper middle class, like the self-employed. Example, a family of four who has no insurance earns $120,000 per year, much too high for any sliding scale services. They pay high property and other taxes that pay for everyone else.
          Suppose this family spends $300 out of pocket every month on doc visits and $500 on medicines. They also pay higher rates out of pocket than those of us who have third party payers.
          This family of four with $120,000 annual income is probably responsible enough to pay the monthly premium on health insurance.
          However, from my own background and looking at a lot of programs, I suspect that the combo of insurance premiums and co-payments will still cost $800 month.
          From my experience, I know how this family could get costly health care. The hospitals can’t turn them away in emergencies and will put them in. I had a relative, an upper middle class woman, uninsured, who had a stroke and only stayed half a night in the emergency room with it because of money!
          She probably had to fight the hospital to go out AMA. They could have worked out a payment plan.
          Her private doctor was later happy to write her up cheap meds and give her samples. But she had no insurance for physical therapy!
          This woman was apolitical and didn’t even vote.
          Church and other nonprofit hospitals will usually do surgery with a thousand or two down and work out payment plan. I know lots of upper middle class types who don’t mind paying $100 or $150 monthly on a payment plan.

  • Suzi Q 38

    He can get drugs from the pharmaceutical company via his doctor.
    The doctor can order it on behalf of certain patients that can not afford it.
    It takes time, but I would order now and then expect to wait a month.

    • querywoman

      Yup! I wish the writer would updated this article. When I re-read it, I saw that the clinic contracts with an outside pharmacy. I’d try to find a church-type charity to help pay for the insulin and then make up a back-up plan.

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