Monday, June 16, 2014

It is A Matter of Life and Death

This is from an email I received today from Dr. R. Scott Poppen at Doctors for America:
After spending 30 years in healthcare, I thought there was no story of bad luck and catastrophic illness that could touch me emotionally. But last summer, as I sat in a hearing room at the Utah State Capitol, I felt a tear well up in my eye.
I was listening to Emily, a woman in her 40’s, testify at the Governor’s Community Workgroup on Medicaid Expansion. In 2009, her 20+ year job with a software developer was eliminated when the Great Recession hit. A few months later she was diagnosed with advanced breast cancer. About the time her surgery was completed, the COBRA insurance she purchased had ended. She was unemployed, uninsurable, and was unable to afford the recommended adjuvant radiation and chemotherapy.
Now, 4 years after her initial diagnosis, her breast cancer had returned and was widely metastatic. In the meantime, she found employment with another company. But that company didn't offer health benefits and she was uninsurable due to her pre-existing condition. Her job earnings made her ineligible for Medicaid and she was the sole caretaker for her parents. She couldn’t afford to see any doctors.
One hour after her testimony I walked into a subcommittee meeting. As our workgroup gathered, we solemnly discussed Emily’s poignant testimony. One committee member, a Utah State legislator and vehement opponent of Medicaid expansion, commented, “We really don’t need to hear anymore testimony like this.” I was stunned.
One year later that legislator is still opposed to Medicaid expansion. His comment still haunts me.
I was sad to learn from news reports that Emily had died. She did finally get on Medicaid. When she became too ill to work, Medicaid enrolled her and provided the hospice care that hopefully eased her passing.
Twenty-four states still have not expanded Medicaid. Doctors for America is actively working in many of these states to get their governors and legislatures to do the right thing and increase access to health care for the working poor. Your donation to Doctors for America helps us do that work and honors the memory and courage of Emily.     

Tuesday, January 28, 2014

What if we Treated Poverty Like a Disease?

In a recent article, author Trudy Lieberman describes the work of Dr. Gary Bloch, a family physician at St. Michael's Hospital in Toronto, Ontario. His idea? Treat poverty like a disease, and facilitate the physician led health care team to access the resources that combat it when they are consulted for medical care concerns.
As the article relates, "We've created an advocacy or interventional initiative aimed at changing the conversation about poverty and how doctors think about poverty as a health issue." To aid in their work, the team has developed a clinical tool used by primary care practices in Ontario that is based on strong evidence linking poverty to bad health outcomes. This tool notes that "poverty accounts for 24 percent of person years of life lost in Canada (second only to 30 percent for neoplasms)," and makes the claim that in Canada,  "higher social and economic status seem to be the most important determinants of health." This relationship has also been demonstrated in the United States.

This is what they do:
1: Screen by asking, "Do you ever have difficulty making ends meet at the end of the month?" Using the language of clinical tests,  the tool says that this question yields a sensitivity of 98 percent (the ability to predict the number of people with the disease) and a specificity of 64 percent (the ability to predict those without the disease).
2: Think of poverty when making clinical decisions like any other risk factor. For example, a man living in the lowest 25% income level has twice the risk of diabetes as a high income man. Therefore, when a man without other risk factors for diabetes presents for care with very low or no income, doctors should consider a screening test for the disease.
3: Intervene with probing questions. One powerful question is, have you filed a tax return? Those who have not miss out on supplemental benefits to help address their poverty. What is their living situation? Many will hide the fact that they have no permanent home.
Like all family physicians, I have frequently experienced hearing from my patients that they are unable to afford their medicines or the treatments that they need, and this has even been true for people with insurance! What if the family physicians office was the gateway to identifying and treating THAT problem?