Go ahead, let’s just make poverty a disease

In a previous post, I described how the American health care system is morphing into a system designed to service impoverished populations, and concluded that the transition “will take time, thoughtful planning, lots of innovation and a carefully cultivated disdain for human life.”

However, a new blog post from Dr. Peter Ubel makes me think that it may not take that much time after all. It seems that Dr. Ubel has been “writing a bit lately on the need for health care providers to talk with their patients about health care costs,” and it seems that some have pointed out that this sounds very much like rationing of care for poorer citizens.

In a Forbes article explaining why this type of criticism is “misguided,” Dr. Ubel is pointing out that individual patients may have different preferences and it is entirely possible that a “patient who pays 20% of the cost of a $100,000 chemotherapy treatment might decide that the potential benefits of the chemotherapy are outweighed by the $20,000 in out-of-pocket expenses they will incur.”  If the empowered patient has $0 in his wallet, division by zero would indicate that the potential benefits of life-extending or even life-saving treatment would be outweighed by a factor of infinity.

Having settled the rationing argument, Dr. Ubel is proceeding to suggest an innovation that should help “providers” bring costs into treatment decisions, not necessarily for everybody, but just for “those who are financially distressed by the cost of medical care.” Since most “providers” don’t know much about costs of treatment, the “financially distressed” will be directed to “walk down the hall and talk to one of the billing experts in the clinic,” because “meeting with this kind of a financial expert will help patients gain a fuller sense of the costs and benefits of their health care alternatives.”

I am not sure how the “billing expert” turns into a “financial expert” in the span of one short paragraph, or how one gains a fuller sense of treatment benefits after a conversation with a coder in the back office, not to mention the technical problems in clinics where the “financial expert” positions were outsourced to India through this or that cloud-based EMR company. Presumably to address these difficulties, Dr. Ubel proceeds to list all sorts of philanthropic Internet startup companies that will help patients figure out costs of care, largely out of the goodness of their hearts. Consistent with his other articles, Dr. Ubel is advising physicians to not “resist this inevitable trend,” but rather “embrace the opportunity to help their patients better understand the full ramifications of their health care alternatives.”

Since unlike Dr. Ubel, I don’t find it “relatively straightforward to imagine a shift in our clinical paradigm, where physicians alter the flow of patients in their clinic” to send poor people to the back, I would like to suggest a different solution which should require no imagination at all. Let’s make poverty a disease, most likely one of those “lifestyle” diseases. Instead of just V codes, let’s give it a few regular ICD-9 codes and plenty of ICD-10, and let’s add a special CPT code for ancillary “financial expert” services that can be billed incident to a physician visit for patients diagnosed with poverty and proper manifestation codes of commercial insurance or no insurance (which is basically the same thing when you have poverty). Note that publicly insured individuals can only be afflicted with unspecified poverty, and do not have out of pocket manifestations, so their claims will fail medical necessity checks and will be denied.

If you think about it, poverty fits very well in the documentation templates of any EMR. For the HPI section, poverty can be acute or chronic and it can have date of onset and duration. It certainly has severity levels, and it can be better with some things and worse with others. Poverty has well known co-morbidities and you can even reasonably document previous treatments. Both the family and medical histories can accommodate poverty in relatives and previous bouts of poverty in the patient. We will need to formally add an organ, or system, to both ROS and exam sections, and the canned normal findings could be something like “wallet plump to palpation, credit scores clear with no discharges and no late payments.”

Poverty with commercial insurance or no insurance manifestations, is of course a secondary ICD code which cannot be billed on its own (you are a doctor, not an accountant), so before you can document your assessment and plan for the primary diagnosis, you will need to send the patient for a “financial expert” session, either in the back of your office, or at an outside facility, just like an x-ray or a cardiology consult. After the patient has been carefully made to understand that the benefits of $100,000 chemotherapy are outweighed by the lack $20,000 in her pocket and the unavailability of assets, loans or other debt instruments, you can complete your assessment and add orders for affordable hospice medications to her plan. This can be done remotely through secure email to save the patient the inconvenience of one more visit, and the care plan can then be shared with the rest of her care team via health information exchange facilities.

Why try to fight this brave new system? Why resist this inevitable trend, when you can embrace the opportunity? And there is indeed great opportunity here. First, reimbursement rates for poverty consultations are bound to be fabulous, and the prospects of “shared savings” are almost boundless. Second, the old coder in the back office may be a poor match for “financially distressed” people, and there is no denying that medical knowledge should help things along, and an MD could be the most effective consultant. So perhaps MDs with MBA degrees will finally be provided with a proper venue to exercise their craft, and perhaps a new specialty will rise to the forefront of value-based health care. May I suggest paupertology (the branch of medicine that deals with ability to pay disorders of the poor)?

Margalit Gur-Arie is founder, BizMed. She blogs at On Healthcare Technology.

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  • QQQ

    “and it seems that some have pointed out that this sounds very much like rationing of care for poorer citizens.”

    A tale of 2 Americas: those who produce, and those who take

  • QQQ

    “Having settled the rationing argument, Dr. Ubel is proceeding to suggest
    an innovation that should help “providers” bring costs into treatment
    decisions, not necessarily for everybody, but just for “those who are
    financially distressed by the cost of medical care.” Since most
    “providers” don’t know much about costs of treatment, the “financially
    distressed” will be directed to “walk down the hall and talk to one of
    the billing experts in the clinic,” because “meeting with this kind of a
    financial expert will help patients gain a fuller sense of the costs
    and benefits of their health care alternatives.” ”
    ———————————————————————————————-
    I just posted this from a previous topic!

    The problems of ACCESS to healthcare and the COST of healthcare are
    related. “Obamacare” is more of an tried attempt to fix the former
    problem, while ignoring (or exacerbating) the latter. And while
    everybody’s got their own boogiewoogie man for the unsustainable costs
    of healthcare – Obamacare, greedy pharmaceutical companies, greedy
    insurance companies, greedy doctors, etc., the real problem is far more
    fundamental: The absurd proposition, that the way to finance all
    healthcare is through “insurance,” public or private.

    The purpose of insurance is to mitigate risk by having a large group of people pay a relatively small amount into a common pool, which makes a large payout to the few people for whom the risk becomes reality. One “insures” against rare and unaffordable loss. But most healthcare does not fall into this category of unaffordable loss that will hit only a few (even
    if some of it does). All of us “consume” healthcare, incurring

    regular and routine medical costs even if we never suffer catastrophic
    or prolonged illness. Insurance is a spectacularly inefficient way to
    pay for such routine care, and its use in this context introduces
    distortions and perverse incentives that reverberate throughout the
    entire healthcare “market.”

    Insurance drives up costs by adding a huge administrative burden to every healthcare transaction, by stifling market-based competition, and encouraging over-consumption by divorcing the price of healthcare services from the patients who use them. Insurance provides the illusion that “someone else” is footing the bill,but there is no free lunch here. Whether through taxes or “hidden” deductions from our salaries, we are ALL paying – and more than it’s actually worth. There are sound reasons why we don’t pay for auto maintenance with car insurance, or most home improvements with homeowners insurance.

    The solution is conceptually simple if politically difficult: Most
    “ordinary” healthcare (doctor office visits, prescription drugs,
    diagnostic procedures, ER and hospital outpatient treatments, etc.) should be paid for directly by the individuals who “consume” it. Leave insurance for what it is meant to be: Protection against “catastrophic” illness.

    Such a change would save enormous amounts of money. Many routine costs (certainly a large proportion of total healthcare costs) would instantly decrease by the ~30% that now goes to administer insurance because there is no longer a “middleman” between healthcare provider and consumer (and it’s not just insurance “profit.” After all, someone must
    generate, process, verify and pay the claims, on both the doctor and the
    insurance side of the transaction. These people also get paid).

    Also,it would eliminate much of the over-consumption that we now see because insured people perceive their healthcare to be essentially “free” to them. People are always willing to spend “someone else’s” money
    differently from how they’d spend their own. Would YOU opt for that
    expensive MRI scan to rule out a break, when your doc says it is most
    probably just a sprain – if it cost YOU $2000 out of pocket? Co-pays
    notwithstanding, there is little real incremental cost to increased
    consumption if you are reasonably well “insured.”

    Finally, healthcare providers themselves will be forced to become responsive directly to the consumer, instead of to third-party payers, which inevitably forces prices down. If you doubt this, look at the costs of
    procedures that are NOT covered by insurance, but must “market” directly
    to the patient like LASIK or cosmetic surgery. They are a fraction of
    the cost of equivalently complex “covered” procedures – and they are
    coming down as equipment depreciates and doctors compete for your
    business. This is what happens in a transparent, competitive market. But
    healthcare is anything but a transparent, competitive market! This is
    because you may be the patient, but you are not the “customer” of
    healthcare providers – your insurance company (or Medicare) is. And
    until the customer is in the equation, there is no market discipline, no
    “competition” – and costs can only ratchet in one direction.

    When the patient is also the customer, everything from the price of drugs
    and medical procedures, to the wait at your local hospital ER becomes
    subject to the same market forces as in every other consumer-facing
    industry. Until people recognize this basic economic fact, and as long
    as insurance remains the vehicle by which all healthcare is financed,
    costs will continue to spiral out of control.

    • Dorothygreen

      whow! First of all consider this. The US does not have a health care system, We have a fragmentation of programs Medicaid – for the poor, Medicare – for the old, ACA for those who are self employed, employer mandated and VA.

      Most of it can be morphed into a health care system based on the Swiss system. The swiss system is insurance as opposed to the Canadian or UK system which is single payer government administered.

      Insurance is OK if used correctly for administration of the program having premiums rates negotiated at the central government. Where there is no such thing as private pay for basic services. And all players must negotiate price. Patients can and should pay something up front, deductibles don;t have to be insanely high as they are now in the ACA . Medicaid must be morphed into the ACA – subsidize the insurance but give it to the patient to purchase and don’t make the process so demeaning, Physicians should be paid the same through all the programs for the basic services being negotiated. Physicians should not be able to even tell who is poor and who is not.

      Forget the “free market” mantra. It does work here. Good doctors can do well because there is choice for It is affordable. Fewer people need subsidies

      So tac the price of basic services on the bulletin board and be done with it. Let the folks who have the money buy the perks they want and can afford. This is through the insurance premium allowing them more some profit. It helps pay for equality in health care.

  • lurking for answers

    Ah, a disease made to have money thrown at it with little chance of a cure.

    This type of thinking would make me entitled to someone’s kidney: they have two, efficiently working kidneys, ergo they are “rich.” I have two, poorly working kidneys, so I am “poor.” I must have one of the “rich” kidneys, because I am entitled to it.

    • SarahJ89

      No, you’re entitled to treatment for your ailing kidney. Or a fair shot on the transplant list.

      The operative word here is “fair.” You seem to gloss over that.

      • lurking for answers

        “Fair” never even enters the realm of chronic illness or failing organs. It is NEVER fair. I didn’t gloss over it.
        But being “real” does. How does society pay for those of us on the costlier end of the illness spectrum? Especially when the very conditions that cause our suffering often impact our financial health and ability to pay for our care.

        Is there a “fair,” viable way for society to pay for every person’s care without bringing the entire society into mutual poverty?

        • SarahJ89

          We could easily stop shoveling money into the maw of Bectel and Halliburton and propping up dictators in our so-called “war on drugs.” It’s a matter of reallocation of resources. You don’t see many other countries wasting their resources this way, do you?

          War of any kind is useless and frightfully expensive. I’d much rather see us pay for your medical treatment. Chronic illness is bad enough.

  • querywoman

    The real problem with Medicaid, and all social services in the United States, is that they are designed for the politically sympathetic, not the truly needy.
    Medicaid covers a lot of pregnant women and children. It’s much harder for a person with a chronic serious illness to get Medicaid.
    That’s part of the American cultural system. American’s don’t like giving help to a 25 year old single childless man.

    • lurking for answers

      Many (if not all) of the social services have been politicized into “entitlements;” they no longer go to those who “can not,” instead they go to those who “will not.”

      There is also no exit from this “assistance” once you get it. I know a person who was “completely disabled” with a spinal condition. Medical science improved to the point where he had surgeries that “fixed” part of the problem enough that he wants to work, but is afraid to even look for a job because the medical benefits will be taken away immediately.

      • querywoman

        Do you blame him for wanting to keep his medical benefits? Insurance, or lack of insurance, is a constant topic on KevinMD.
        Nevertheless, both Medicaid and Medicare have stuff written in them about keeping medical benefits a while. I’d have to look that up!

        • lurking for answers

          Do I blame him? NO! There is a good chance that he will need to have more surgeries in the future. But, I have watched as this brilliant mind has been tortured by being trapped in first a crumbling body and now a broken system. The mental toll of wanting to use your skills and be useful, but not being allowed to do it because you may need further medical care is so pointless and beyond frustrating.

          A safety NET is a good, right and compassionate thing. But it should be a NET not a NOOSE! There needs to be a supportive way out.

          • querywoman

            Your friend is probably younger than I am.
            My own brilliant mind was tortured and captured to a skin disease for years, which was not the original reason I went on disability.
            I have improved enough to take one art class per semester. I have to do something with my life.
            I am 58 and went on disability ten or twelve years ago with the knowledge I would be reviewed every few years and the assumption I could return to work.
            I just passed my last review and got told I can stay on RSDI. This may be last.
            Of course, as I age, I develop more age-related problems. I have had pneumonia twice in the past two years, and once got locked up for 8 days.
            I know that I could clean up at what used to be the Texas Rehab Commission with job retraining services. I might be interested, if I thought I could work.
            When I first went on disability years ago, I tried that. I developed the strange skin problem about 1 year after I went on disability, and my caseworker and I agreed I couldn’t work at that time.
            I have intention of getting better, continuing to improve, continue my education, sell my artwork, teach art or something.

          • Patient Kit

            I’m in a similar position myself right now. I’ve been back to work for 9 weeks now, full-time but only freelance with no benefits, including no health insurance. So far, I still have transitional Medicaid but that is sure to end soon. I’ll be sure to let KMD know how it goes — whether I go without insurance, whether I try my luck on the exchange, whether I skip seeing docs for a year or so, whether my ovarian cancer recurs or not. But I had to get back to work. I need to keep a roof over my head and eat occasionally.

          • lurking for answers

            May you go forth and prosper.
            May you have the riches of a good life and good health.
            I have been free-lance since I was 17, it is difficult, but rewarding and the only way I’ve found to work/do what I love while being chronically ill (especially before I knew I had the disorders I have!)

      • querywoman

        Has he tried working with his state rehabilitation commission, or whatever it’s called now? I allege that, as much as companies gripe about taxes, they’d really rather pay higher taxes than hire sick people.

    • Patient Kit

      It’s about sorting people into the deserving and the undeserving. Innocent children deserve help. No longer innocent adults (or is that guilty adults?) do not deserve any help at all. Guilty pregnant women, unfortunately, have to be helped because there is no way to help the child they are carrying without helping the mother. The same is true of moms with dependent children. If we want to help their kids, we inadvertently also help their moms. In many states, adults in real trouble and need of real help who don’t have any kids can go jump in a lake or live under a bridge.

      • querywoman

        In Texas, a 21 year male US citizen with no children and leukemia will get treatment at a county hospital district. He’s young, has not worked very long, and has not paid much into Social Security.
        He might get SSI, which includes Medicaid, if he responds to the treatment and lives long enough to get disability payments.
        I saw such a young man when I worked in Texas welfare.
        I could only give him food stamps. But, I could provide Medicaid for the days an undocumented alien woman spent delivering a baby in the hospital and also Mediciad for her US citizen child.
        The other side of this issue is that hospitals pressure the government to give them payment for undocumented alien mothers for their deliveries only. Without Medicaid, state, local, and hospital funds eat the health care costs.
        The real reason behind all social services in this country is to benefit the provider. Food stamps benefit the food growers in this country.
        There are many more pregnant women in this country at at any time than single childless young men with major illnesses.
        You don’t see much in talk about reducing medical costs on how to get low cost care out to really sick people.

        • Patient Kit

          I’m very grateful that I live in NY.

          • querywoman

            Yeah. My coworkers from other states told me that single people w/o children could get Medicaid in other states.

          • Patient Kit

            It’s certainly true in NY and, in my case, Medicaid likely saved my life.

          • querywoman

            Oh, by the way, Governor Rick Perry thinks the medical status quo in Texas is generous.

    • Rob Burnside

      Bingo, QW! You’re exactly right, it is a cultural boo-boo more than anything else. And it goes back at least as far as the first Hollywood screenwriter who used “Go on without me boys, I’ll only slow you down.” Through third party billing, we have, arguably, the world’s best EMS because the cultural shoe fits

      However, with a huge number of aging Boomers encountering chronic illness for the first time, priorities may change. If we can do for Lupus or RA what we’ve done for the garden variety AMI, wouldn’t that be something!

      • querywoman

        Glad you like it. The ACA got rid of the pre-existing conditions, but with $7200 annual premiums and $6000 annual deductible, who does it help the most?
        The insurance companies!
        As we age, though, we become more politically sympathetic. People who have diabetes or heart programs always get blamed for our illnesses. Those are genetic, hereditary illnesses.
        The Texas medical system has a horrid disparity. How did a 21 year old citizen man cause his leukemia? Why can’t he have some kind of medical insurance to go to any cancer clinic in town? Also, to get his supplies? Waiting all day at a public facility can’t be easy for him.
        By the way, he looked just like any average young white man, except for his bald head.

        • Rob Burnside

          Ever considered going into politics? I’d vote for you any day.

          • querywoman

            I’m too liberal for Texas, the state that gave the feds Senator Phil Gramm and currently has Governor Rick Perry at its own helm.
            Sen. Gramm is much smarter than Gov. Perry!

          • Rob Burnside

            Start with City Council.

        • Lisa

          While I agree with you about the Texas medical system being horrid, I’ll take exception to you saying that the ACA has brought us $7,200 annual premiums. I’ve looked at all of the plans available on the CA exchange and the cost is less than that, even for the best plans. Furthermore, you are discounting subsidies. Many/most people are getting insurance for quite a bit less.

          • querywoman

            When I looked for friends under the 300% poverty level, I mostly saw plans around $600 per month, with $6000 deductibles, that included maybe 3 preventive visits cheap or free per year.
            And I figured they would get about $550 per month in subsidizes, and they would still be paying $50 per month out of their own pockets.
            Maybe the price has fallen some after the plan got rolling.
            If you are getting a large govt. subsidy, it still goes to the insurance companies as payment and enriches them.

          • Lisa

            Yes the premiums go to insurance companies, but remember that the insurance companies have to spend at least 80% of premium dollars on medical needs.

            The ACA is far from perfect, but it is still better than nothing.

          • querywoman

            We’d have to audit the insurance companies to see how it’s working.
            Generally, supplementing the income to pay with a voucher to a private business is a Republican way to do things. I dislike the tax subsidies, among other things, for adding more complexity to the income tax form.
            Many Americans just hate the idea of paying more tax to fund health care, but I feel like the ACA system costs more.
            We shall see!

          • SarahJ89

            I refuse to sign up for Medicare Part D because it’s a welfare program for the insurance companies. It didn’t help that when it began I was not on any medication. There was no way to sign up because the first step was to “list your medications.” Wha??? What’s up with presuming everyone is on meds??? And how is that insurance? It’s more of a prescription subsidy plan.

            It looked like a train wreck to me and I decided right away I wasn’t going to have anything to do with it.

          • querywoman

            You probably don’t need it them. I’m on some expensive meds: my Victoza diabetes med and asthma inhalers. Plus, a bunch of other cheaper meds.
            I agree that it’s welfare for the insurance companies.
            It’s still a train wreck after all these years.

          • SarahJ89

            I know. I’m really surprised. They usually fix these legislative train wrecks much more quickly. It doesn’t feel good to see this one still chugging down the tracks.

            At this point I’m finally on a medication! Ten dollars worth of thyroid. I’d like to enroll my dog on Part D, though.

            If things change I’ll have to suck it up and do it. At least now that I have ONE med I can actually sign up. There’s no where to go if you’re not on meds.

            I find this business of wholesale medicating of the population disconcerting.

          • querywoman

            Yeah. You don’t need Medicare D. Just a cheap generic. So your dog needs meds…hah!
            On listing your meds, they are trying to compile what you take, the costs, and show you different plans.
            The Medicare D has been fouled up since it’s inception! So now comes the ACA! I predict 10 more years of confusion!

          • SarahJ89

            My dog. Meds. We spent last night until 3:00 am spending our retirement savings on Dog #2. Dog #1, his mother, has her own little pill organizer now. The two of them have been extraordinarily health for years but seem to be spending their vet budget in one week.

            What the heck. We were only going to spend that money foolishly on silly stuff like food and shelter.

          • querywoman

            And vet meds should be cheaper, but they add up on sickly dogs!

  • southerndoc1

    I have applied for NCQA certification as a Poverty Centered Medical Home.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      You have?? :-)
      I remember oh maybe 4 or 5 years ago trying to explain to a journalist that medical home is not a homeless or “indigent” notion. More irony, I guess…..

      • southerndoc1

        Apparently, lots of patients think it’s some kind of fancy nursing home. The branding hasn’t gone too well.

        • SarahJ89

          I just know that when administrators tell me something is “patient centered” that it most assuredly is not.

  • Markus

    Former oncologist here. We commonly did exactly as described in the article. Oncology services are costly, and insurance coverage was spotty and had approval barriers as far back as I can remember. Our office and the offices of oncologist had reimbursement specialist who commonly talked to the patients. Our EMR had a button to push for imbursement approval before we started treatment. Ironically, the process often went smoothest for the Medicaid population; private insurance companies consider premium payments as their money and are more reluctant than a governmental agency about disbursements.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Yes, and in my infinite naiveté, I thought that we just enacted an Affordable Care act, to address exactly those issues.
      As I said on a previous post here http://www.kevinmd.com/blog/2014/07/hypoliquidemia-now-come-health-care.html the only viable (pun intended) choices remaining are public welfare or mansions in gated communities…. It is indeed ironic.

      • doc99

        The Patient Protection and Affordable Care Act neither protects patients nor makes care affordable. Go figure.

    • Patient Kit

      You’re going to make me start weeping. I’ve said many times here on KMD that navigating our healthcare system was surprisingly much scarier than being diagnosed with cancer. Of course, in my case (so far), I was early stage OVCA and only needed surgery, no chemo. I think that if I was advanced stage and needing chemo, the cancer would have been scarier than our healthcare system. Or maybe they would have been equally terrifying.

      I have been covered by Medicaid for the last year and a half since my layoff/loss of BCBS insurance, which inconveniently happened right before my dx. I’m supposed to have follow-up surveillance 4x a year for 2 years, then 2x a year for 3 years, then annually after 5 years. But hey, maybe the working poor and uninsured don’t really need that follow-up monitoring. Not sure I’m going to be able to do keep doing it. I’m going to try.
      I can’t even imagine needing chemo and not being able to get it solely for financial reasons. That, to me, is just obscene. It shocks me that some people are ok with that. We really need to reform our system in a way that every American can get all the cancer treatment they need. It amazes me that some people object to that idea. Chemo shouldn’t be thought of as a luxury, like a BMW.

      • Markus

        Stay brave, Kit. My forty years of experience saw excellent outcomes in situations like yours. One good thing in recent times is the elimination of pre-existant conditions clauses. In the bad old days, people would have trouble getting coverage. My sincere best wishes for your continued good health.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          That was a good thing, but it needs extensive work because the insurers turned this into a very clever shell game. Here is an interesting assessment and plea from those who care for/about people with serious chronic disease
          http://www.theaidsinstitute.org/sites/default/files/attachments/IAmStillEssentialBurwellltr_0.pdf

          • lurking for answers

            This was happening prior to the ACA. Insurance for illness prevention is great, but its next to useless once you are already sick. This has been my issue with absolutely every option that has been run up the flagpole. None of the options have addressed the needs of the chronically ill.
            Insurance is also useless if there are no doctors willing to treat you. “Lemon-dropping” has been a growing problem in American and other countries health systems for some time. A recent “Blackjack” blog here practically encouraged it.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            …which is very interesting to me, because we are observing the emergence of a new narrative advocating for a “health care” system instead of the current “sick care” system. On the surface, this sounds like a worthy cause, keeping people healthy and so forth, but a system that shifts the bulk of its resources and focus to diet and exercise managed by iPhones and group sessions with dieticians cannot in all honesty be expected to properly care for the seriously ill, because this is increasingly not its mission. Collateral damage?

          • lurking for answers

            What the docs are not realizing is that the practice of medicine itself will be the collateral damage. How will you learn to care for illness if you never treat the ill? Knowledge will be lost as well as lives.
            If the chronically ill are shunned, forgotten and simply allowed to die of their diseases while doctors turn a blind eye, it does not bode well for society.
            I have seen no feasible way to pay for the ever increasing costs of chronic illness put forth by anyone, political or otherwise. It seems to be the unanswerable question, heated by the forces of financial logic versus compassion.

          • ErnieG

            I am a physician. I’d like to expand briefly on your observation of the new narrative of a “health care” v “sick care” system. I do not like the designation of medical care as “health care”. Physicians are trained to diagnose and treat disease, not to keep people healthy. Being sick increases morbidity and early mortality, and what medical care and payment reform should address. Being sick causes financial hardship and personal bankruptcy. Preventive care usually does not. While seeming harsh, I do not see why medical insurance needs to pay for screening tests which are budgetable. Using insurance to pay for screening colonoscopies, mammograms, etc is really just increasing the administrative costs AND involving insurance even more in the process. I would argue the same for treatment of uncomplicated hypertension and hyperlipidemia– these are low cost, budgetable, and unlikely to cause financial hardship. Free up that money for the person with acute appendectomy, for the COPD/CHF with AKI, for the MS, etc.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I agree, with certain caveats. I think preventive care and the things that now go by “lifestyle” issues (which in and of itself is a very cruel and discriminatory terminology) could be left out of standard insurance, if insurance would come without high deductibles, and if we could come up with some form of progressive subsidy for those who cannot afford to pay for their body’s ongoing maintenance, so to speak.

            It is extremely disturbing to see how the public is being lured into a system that will by definition withhold big ticket catastrophic care, while freely dispensing trinkets to all comers.

          • SarahJ89

            “It is extremely disturbing to see how the public is being lured into a
            system that will by definition withhold big ticket catastrophic care,
            while freely dispensing trinkets to all comers.”
            This. about 1000 times. I hate the “free” gym membership that comes at the expense of later care.

          • SarahJ89

            I wish health savings accounts weren’t tied to jobs. I totally believe in saving for any planned for expenditure. My sweetie had a HSA for about 8 months and it really was a motivator to save for glasses, etc. (We aren’t much for screening. Okay, we don’t do screening.)

          • querywoman

            Your common sense hurts! I call, “preventive medicine,” as, “when sick people can’t get medical care.”

          • SarahJ89

            Not to mention that not all of us are happy gym rats. Some of us swim 45 minutes a day within 15 feet of nesting loons teaching this year’s babies how to fish. Or we walk two miles into the woods to pick berries, then two miles out. Or we bike. Or do anything that doesn’t involve being indoors or wearing spandex.

            But that’s not as easy a fix as a gym membership.

        • Patient Kit

          Thanks very much for your kind words of encouragement. I really do know how lucky I am, all things considered. It was a true blessing to find my OVCA at such an early stage and to find myself in the hands of such a good doctor. I know intellectually how good my prognosis is. My excellent GYN ONC has stressed that my prognosis is very good but there are no guarantees. Regardless of how good my scenario is intellectually, scientifically, medically — it’s still sometimes a little scary emotionally because, well, it’s cancer. Because I’m being monitored every 3 months, I reason that they’re looking for something. But sometimes I feel like, because I was only stage 1A, I don’t really have the right to be scared by the big C. I know that many, many people have suffered with this disease far worse than I have.
          Maybe I think too much (!), but sometimes I can’t shake the feeling that just as I landed in the lucky 10% of women who are diagnosed with OVCA in stage 1, I could end up in the unlucky 10% of women whose stage 1A cancer recurs.
          Other than my struggle to find a way to stay covered by health insurance that will cover my pre-existing condition (thank you ACA!), I mostly have moved on past the shock and fear of my diagnosis and am planning on clawing my way back into the middle class and living a long and happy life. Next year, once I’m back on my feet further financially, I’m going to swim with whalesharks in the open sea in Mexico. That’s high on my long bucket list. And it’s going to be done with some friends as sort of a celebration of my surviving cancer.
          Regardless of what happens to me personally going forward, I will never forget the horrifying feeling of being diagnosed with cancer while uninsured and facing the daunting task of trying to find help in our healthcare system. I won’t rest until we have a humane healthcare system in this country in which every American can get the medical help they need when they need it and nobody has to just go without needed surgery or chemo or anything else they need regardless of their socioeconomic status when their illness or injury hits. It’s been a life-changing experience and there is no going back and unknowing the kind of fear that too many people have to face every day in this country.

  • buzzkillerjsmith

    Disease? How about a crime?

    Prisons are full of the mentally ill so there is precedent for incarcerating those more victim than oppressor. We could put the little kids in juvie or even use the Jonathan Swift solution but state laws might have to be adjusted a bit for the latter.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Love your modest proposal….
      But seriously, we could start with bringing back debtor prisons which were prematurely abolished. We could probably reclassify the captains of the booming private prison industry to be the new job creators….

      • Patient Kit

        Yes, let’s put poor people in prison and then make them work hard for free for major corporations to pay for their prison meals and the prison roof over their head. Free poor American prison labor is even cheaper than cheap labor in China. Win/win.

        • querywoman

          We used to have a state Senator in Texas, John Leedom, who wanted to send your worst criminals to Red China.
          Why would Red China want them?

      • southerndoc1
        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Fantastic…. we are reforming the “health care” system to match our “justice” system and for that matter, also our “education” system. Natural “progression” I guess (too many quotation marks)

  • southerndoc1

    Dr. Ubell’s fantasy is based on the assumption that people like him will never be among those asked to walk down the hall to talk to the billing clerk, I mean financial expert.

    • Patient Kit

      Yes and I’m about to have a mean-spirited revenge fantasy about people like him.

  • Patient Kit

    “…paupertology (the branch of medicine that deals with ability to pay disorders of the poor)…” You’re making me weep, Margalit. Our healthcare system’s capacity for inhumanity and obscenity is just heartbreaking and terrifying. :-(((((((

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Don’t weep, Kit. It’s not “our health care system”. It’s the same shady characters that are trampling on people in every industry and at every opportunity, and there are trillions of dollars in health care, just sitting there…. You know where the root cause is, and that’s what needs to be addressed….

  • querywoman

    Do the poor get the best possible care since they are often seen at the medical schools? Sometimes, the schools are substandard, but still need training subjects. So, in well-developed specialties, the proof will get all kinds of procedures.
    The rich can afford to go anywhere.
    It’s the vast middle in-betweeners who can’t.

    • JR DNR

      95% of a diagnosis is a good case history. Many doctors are pressured to not spend much time taking a case history because they take too long. Med schools have students paying for the privilege of taking case histories.

      • querywoman

        Hmmm…the first time my father was in the VA, he had a roommate. And we heard the medical students taking a full history.
        The roommate’s basic problem was he had drunk a pint and a half of whiskey every day for about 10 years.

        • JR DNR

          I would say the basic problem isn’t the alcohol, but the reason he’s drinking the alcohol. People who use drugs or alcohol have something painful they need a coping strategy to deal with. Unfortunately, instead of a healthy coping strategy, they’ve turned to alcohol or drugs.

          In order to treat the addiction, the underlying trauma has to be addressed.

          This is a pamphlet from for further reading (note it’s from 2001):
          http://www.istss.org/AM/Template.cfm?Section=PublicEducationPamphlets&Template=/CM/ContentDisplay.cfm&ContentID=1461

          This is a review of a study about Childhood Trauma and Alcoholism (from 2013):
          http://www.huffingtonpost.com/joseph-nowinski-phd/alcohol-abuse_b_3595743.html

          • querywoman

            My comment wasn’t about the alcohol. It was about the thorough, lengthy the history the med students took.
            Of course, it only took him a few minutes to spit out the truth.

            Daddy used to get drunk in the military. Before he married Mama, a military doc had told him to quit drinking or it would kill him. Never drank that much during my lifetime! I got drunk when I was younger in college.
            But, when that old guy spit that eye, Daddy’s eyes just rolled! I was already working in public welfare, and had seen my share of messed up humans.
            Most people don’t stay drunk constantly.
            That night the old man tried to smoke a cigarette and started a fire in the trashcan.
            Daddy’s heart rate went way up. There are stupid questions. They wheeled him off to some machine, and asked him, “How come your heart’s so fast?”
            He replied, “H*ll, I’m mad!”

          • JR DNR

            Ahhh got it. I was thinking along the lines of “to treat the alcohol addiction you have to treat the underlying problem under the alcohol addiction”.

            I have a great grandfather who died from alcoholic liver disease. I was always told he was an alcoholic and a drunk. Yet… no one currently alive ever remembers seeing him drunk or even seeing him with a drink. One of his grandchildren who does not drink at all, not even socially, now has non-alcoholic fatty liver disease.

          • querywoman

            Yeah, they don’t know everything about liver disease.
            Another point of this guy, and I wonder if it is still the same, is the roommates business was private! We didn’t need to hear it.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Yes, I do realize that. However, I would have expected, at the very least, some moaning and groaning, accompanied by multiple suggestions of how we should fix the problems. Instead, the real dysfunction of the system is presented as an aspirational goal, by a physician, no less.

  • lurking for answers

    If diet and exercise are the best way to avoid chronic illness (in the majority of the population,) shouldn’t the best way to avoid chronic poverty be a BUDGET and WORK?
    When did poverty become genetic?

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      It’s not genetic. It’s generational, or environmental.
      All the diet and exercise in the world won’t save you if you live where the water is poisoned and the air is loaded with chemicals. Similarly all the budgeting and working in the world won’t help much if you are born where education is broken, infrastructure is dilapidated and all the jobs were moved to distant shores by those who never needed to budget or break a sweat (other than at the country club gym) in their entire life.

      • lurking for answers

        The current treatments for poverty are highly addictive and reach through generations. Again, I would compare these treatments to a noose you cannot escape and not a (safety) net to break your fall.

        To remove personal responsibility from either of the concepts of personal or financial health denies the person any hope that their positive actions can in any way change their circumstances. When you believe that any change must come from outside and you must rely on something else to save you or make you better, it denies the dignity of the human will.

        No doctor here would tell a 300 pound, type 2 diabetic to just keep taking his meds and keep doing what they are doing and accept that they will just die sooner. Why do we do that for poverty?

        Is this nation such a wasteland of corruption that no one can hope for better for themselves or their children? If any change can occur, it has to come from within, in ones and twos and families and then generations. To ask the current “powers that be” to change a broken system is to ask the very people who broke it!

        • Patient Kit

          I understand what you’re saying about how the system traps many people in poverty and keeps them exactly where it wants them — down — and out. But I have to also say that, in my case, Medicaid functioned as a true safety net for me until I could get well and start to get back on my feet. Medicaid likely saved my life. Until the pre-existing conditions clause of the ACA kicked in on Jan 1, 2014, however, I was trapped in a place where I couldn’t work without losing Medicaid, the only insurance that would cover me pre-ACA. Very scary situation with a new cancer dx.

          Going forward, I have more health insurance options (I hope). In my case, I temporarily fell out of the middle class when I got laid off, lost my insurance and was diagnosed with OVCA. But I have a lifetime of good, marketable skills to help me get back into to the work world, now that the threat of no access to healthcare at all has retreated.

          I will never forget the terrifying feeling of facing a serious dx like cancer with no access to healthcare though. And, to me, it is obscene and inhumane that anyone in the US finds that situation acceptable for any Americans, regardless of their economic class at the point in time that they get sick or injured.

          • lurking for answers

            It gives me hope that the system worked as it should in your case.
            “But I have a lifetime of good, marketable skills to help me get back into the work world…”
            Your “good, marketable skills” are your “physical therapy” out of poverty. I would say that that is your “best treatment.”
            What about those born into the poverty-treatment-system whom have NO marketable skills? What will their “treatment” to remedy their “financial illness?”

            If we “medicalize” poverty, there should be a “treatment, therapy or cure” instead of an addictive, destructive loop that maintains and encourages the original “illness.”

          • JR DNR

            You know that the average aid receipt is white, middle class, suffering a crisis financial situation (such as a health crisis or job loss), and is only on aid for a very short time?

        • SarahJ89

          Let me take you down… not to Strawberry Fields, but to communities with NO industry and no transportation and no high school past tenth grade. The families have to chip in to buy a beater car. They have one designated driver who drives the other students 26 miles one way each day on a twisting road along a major river. There are no buildings for 13 miles of that road. The mountain winters are harsh, often 30 below at night for weeks at a time. The nearest other town is 26 miles in the other direction through a treacherous mountain pass, again with almost no habitations. Or you can travel in the other direction through a less treacherous pass to the Big City. Of Rangley, Maine.

          People feed their families with deer they jack illegally. The traditional forest jobs have gone with the paper mills to China. Most of the small children in town have brown stubs instead of teeth by the age of four (you can tell real poverty by the teeth–or lack thereof).

          Now tell me how curable that poverty is.

          • lurking for answers

            “Now tell me how curable that poverty is.”
            How do you propose it be treated?

          • SarahJ89

            I don’t. I don’t think this kind of wholesale economic collapse of an already marginal region can be pulled out of it by anything but jobs. And that’s not likely to happen. Education is the best way out of poverty that I know of, but you can see what it takes in that are to simply get a high school diploma.

            My impression was that you seem to think you have the answer to poverty. Or that current systems are a failure entirely. They often are not.

          • lurking for answers

            Actually, I don’t have the answer to poverty. I have not seen any society in human history that has had the answer to poverty; it has followed us from the beginnings of people.
            There are, however, treatments that work. I wholeheartedly agree that education is the best way out of poverty, but education is not a one-sided transaction. One side teaches and one side must learn. If the student does not try to learn, very little can be taught.
            To take the poor person’s responsibility for their own well being away from them is wrong. It tells them that there is nothing that THEY can do to escape their circumstances and robs them of human will and dignity.
            In those places where the economy has collapsed, I question if anything other than the poorest society is possible. If viable jobs (work) can’t be brought into that place then paying “assistance” to keep those people there is as cruel as chaining a dog to a tree in the back yard and tossing out bones when you remember to do so.

          • SarahJ89

            Here’s what I have seen in small New England towns: families whose children are systematically denied opportunity from an early age. They are allowed to come into the library, but not to borrow books. Permission is given to other children to bully them and treat them like pariahs. The primary grade teachers are hugely instrumental in this process. By third grade they know their place and will not be troubling anyone for upward mobility. The process is subtle and unrelenting.

            After that you can offer all the feel good opportunities you want. It’s especially effective in “proving” how unworthy “these people” are to offer great opportunities in high school, secure in the knowledge no one will take you up on them. The nearest town with a pharmacy is 25-30 miles away. The pharmacist won’t sell you condoms, plus the expectation from childhood has been you’ll get pregnant and have to drop out of high school.

            And just what *is* the place of these children? To be low level laborers in the local box shop, crutch factory (broke a leg in my husband’s town? You get a free crutch!) or sawmill.

            Traditionally in our small towns the role of the families comprising the underclass is to serve as a low level labor pool for the two or three families in town who own the small factories.

            Those factories are gone now. But the legacy lives on.

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