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?

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Amol Sura is a 2nd year medical student at LSU Health Sciences Center- New Orleans and a contestant in the 2012 Costs Of Care Essay Contest.

]]> http://www.costsofcare.org/thechallengesoftreatinghomelesspatients/feed/ 1 http://www.costsofcare.org/connectingcostsandquality/ http://www.costsofcare.org/connectingcostsandquality/#comments Mon, 13 May 2013 08:00:02 +0000 Jordan http://www.costsofcare.org/?p=1462 By Sam Wertheimer

My research on cost measurement in health care has shown me that physicians can improve the value of care through better collaboration with financial managers.

Financial managers include business analysts, supply and equipment purchasers, operations specialists, and human resources staff. These personnel plan budgets, monitor spending, hire personnel, and report financial performance to top management and external stakeholders. Despite the vital role these staff members play in supporting clinical operations, financial managers are often disconnected from front-line clinicians.

At the same time, those front-line clinicians are often disconnected from the finances. Evidence of this can be found in a recent study showing that posting prices next to lab test options changes physician behavior. In this study cost-conscious physicians ordered significantly fewer tests.

Bridging this disconnect is critical. Physicians should be able to discuss business decisions, like purchases of the supplies they use or hiring of personnel they work with, with financial managers. During these discussions physicians can provide details regarding the clinical implications of the business decisions while the financial managers can provide further insight regarding revenue and expense implications. This communication facilitates balance between costs and outcomes and optimizes patient value.

An example of this occurred recently at one of the hospitals where I am studying health care cost management. At this hospital, physicians and financial managers teamed to discuss purchases of surgical supplies for total knee replacements. They focused on knee replacement equipment because this component of care was highly variable – both in cost and in clinical practice. The discussions proved fruitful when the group found that standardizing the set of available hardware the hospital could order larger supply batches and no longer needed different sterilization techniques for each different type of equipment. Quality was maintained despite the decreased equipment options because, with fewer choices, clinicians could more readily share advice and best practices, and this increased operating teams’ skill.

Another example of improved communication occurred at a hospital where cost-conscious plastic surgeons discussed hiring clinical support staff with human resources managers. This group compared financial models to clinical outcome predictions and found that hiring one new ancillary provider would likely improve quality, however, this change would result in increased costs per patient. However, the surgeons and financial managers also found that hiring multiple assistants could effectively streamline care processes to facilitate both lower costs per patient and improved quality.

These examples show that motivated physicians in various clinical settings are equipped to communicate and collaborate with financial managers to improve patient care and value. Becoming aware of actual care costs erases the current divide – then it’s just a matter of reaching out.

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Sam Wertheimer is a Research Associate at the Harvard Business School. There he focuses on identifying opportunities to improve health care value through accurate cost measurement.

Experts, most recently former CMS administrator Don Berwick, tell us that no less than 20% – 30% of medical care is “waste.” At the very least, “waste” is harmful to all those who pay for Medicare. But often it’s directly harmful to the patient as well.

I recently saw a friend at a party. Since we’d last seen each other my friend’s spouse had died. (I’m deliberately avoiding gendered pronouns and omitting other identifying details.) My friend contrasted the excellent hospice care the spouse received with problem-ridden hospital care. Here are two examples of “waste” that were thwarted only by my friend’s vigilance.

My friend’s spouse (“the patient”) was declining rapidly, and was admitted to the hospital. While my friend was attending to some bureaucratic aspects of the admission, the hospitalist ordered a CT and insertion of a “picc line” (“picc” = “peripherally inserted central catheter”).

On returning to the patient’s bedside my friend pointed out that an identical CT scan had been done four days earlier.

The hospitalist responded – “I don’t have it.”

My friend replied – “Rather than putting such a sick person through another CT and spending another few thousand dollars, let’s get it.”

With regard to insertion of the catheter, my friend asked: “what aspect of the plan does it serve?” The answer was – it was an automatic part of a protocol, not tailored to the wishes of the patient and family. When their goals were clarified, the picc line idea was dropped.

I know from my own practice experience that getting test results and records can be difficult. But repeating an identical test four days after it had been done elsewhere is a very expensive workaround that would have imposed avoidable distress on the patient. And although threading a catheter to place near the heart is a fairly routine hospital procedure, it carries risks (such as infection) and burdens (being hooked up to tubing). The hospital protocol should have required clarity about treatment goals before a non-emergency intervention was set into motion.

What struck me about these examples of overtreatment is how mundane they were. The hospitalist meant well. It was important for him to have the information the CT scan would provide, but repeating it wasn’t the right way to get it. And having routines can promote patient safety – but only when the routine is tailored to the true situation. In a non-emergency, getting clarity about the treatment goals of patient and family should be part of what we physicians routinely expect of ourselves.

My friend improved the spouse’s care and, at the same time, reduced costs. The public won’t be ready to consider reduced Medicare benefits or rationing until this kind of lose/lose waste is eliminated from the health system!

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The following post is by Jim Sabin, a Clinical Professor in the Departments of Population Medicine and Psychiatry at Harvard Medical School, Director of the Ethics Program at Harvard Pilgrim Health Care, and a blogger at the website “Over 65.”  Jim has been in healthcare for almost 50 years — as psychiatrist, medical director, teacher/researcher, consultant, leader of the ethics program at a not-for-profit health plan, and patient.

The pressure on physicians to provide better care at lower costs is coming from all directions – top down from policymakers who want more accountability in how healthcare resources are being used and bottom up from patients who want more transparency in how their money is being spent.  Obstetrician and gynecologists have not been spared any scrutiny. As primary care providers for many women we are in thick of the debate on appropriate use of pap and mammography screening. As surgeons we also find ourselves increasingly answering for the expense and morbidity of unacceptably high c-section rates.

While our clinical breadth provides ample fodder for scrutiny, it also may uniquely position us to help patients choose wisely among the growing panoply of diagnostic and therapeutic options. One of the most commonly encountered and difficult decisions that patients encounter is, “should I pursue medical management or surgery?” Like other specialties, ob/gyn’s are seeing surgical indications shrink as medical therapies become increasingly available and effective. Unlike other specialties, we often continue managing the patient’s condition whether she chooses surgery or not.

In a brave new world of increased healthcare scrutiny, the value of each option is only clear in comparison to the alternatives. Generally speaking, a trial of medical management is almost always preferable to surgery, even when the medicine is expensive. Take tranexemic acid (commonly marketed as Lysteda in the United States), recently approved by the FDA to treat menorrhagia: the retail price is generally more than $170 per month. However, for the correctly selected patient for whom there are limited safe medical alternatives, it is well worth trialing over the potential pain, inconvenience and several thousand-dollar price tag of surgery. Leuprolide acetate (Lupron), most often used for endometriosis-related pelvic pain, is another example of a very expensive medication (close to $1000 for a three month dose) that could be a good value for the correctly selected patient who does not want to commit to an operation.

Opportunities to help our patients get a good value extend beyond those who wish to avoid surgery. The most common group of medications prescribed by ob/gyn’s are oral contraceptive pills (OCPs), given for a variety of non-contraceptive indications ranging from endometriosis to irregular menstrual cycles. Although there are hundreds of readily available OCP formulations, most of us generally prescribe a small subset that we are most familiar with and consider a limited set of clinical factors. It appears that making cost one of those factors would be particularly worthwhile. Prices of OCPs vary by an order of magnitude. Many available generic options cost less than $10 per month while the newest brand formulations can cost closer to $100.

Despite routine opportunities to help patients make high value decisions, this is often easier done in theory than practice. Patients may present for care with fixed expectations and taking the time to counsel them about the full range of available options is already challenging. Adding cost information to this task creates an extra dimension of complexity. Moreover, cost and value are not always easily ascertained and will typically vary according the patient’s clinical circumstances, personal preferences, and particular insurance plan.

Fortunately, there is a growing body of resources available to help. Medication costs can now be queried online by pharmacy at sites like GoodRx.com. Professional societies, including the American Congress of Obstetrics & Gynecology, are developing lists of high yield opportunities to improve value. Organizations such as the American College of Physicians and Costs of Care provide online training opportunities in cost-conscious care. Choosing wisely and delivering value in obstetrics and gynecology is not always easy or straightforward but I truly believe that we are up to the task.

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Neel Shah, MD, is a chief resident in obstetrics and gynecology at Massachusetts General Hospital and Brigham & Women’s Hospital in Boston, MA. He is also the founder and executive director of Costs of Care, a grant-funded 501c3 venture. He can be reached at neel@costsofcare.org. 

“Have you ever been told you have a heart murmur?” a young doctor gently asked my friend, Ben. Ben’s mind reeled. Ben was in his early 30s, relatively young and healthy.  But his father had died from a heart attack before age 50. And his mother had a heart problem.  What did this question signal for him, he worried.

“Um, ah, no, I haven’t,” Ben managed to murmur in reply.  The doctor told Ben he wanted to get a sonogram to have a picture of Ben’s heart. He scribbled an order on a form and told Ben of a nearby cardiologist. Ben thanked the doctor and wrapped up his appointment. As soon as he left, Ben called me. We have been friends since grade school, and we shared everything. When I heard his voice I could tell he was upset.

It was his first visit to the new doctor, a young physician at a trendy new concierge practice. He said he worried the doctor was jumping to conclusions in his recommendations. Puzzled, I reminded Ben that the test was merely a preventative measure. But, I suggested, with his family history, he would be wise to get his heart checked out.  An ounce of prevention is worth a pound of cure, I teased. Then the real truth came out: Ben was worried about the cost of the test. Ben explained he called the cardiologist before he called me. He was shocked to learn a sonogram was $1,200 if he paid out of pocket.

“Twelve hundred bucks?” Ben complained over the phone. “That’s outrageously expensive for a simple test,” he whined. I found myself  momentarily distracted by wondering about the costs of technology, malpractice insurance costs, physician practice trends, but I bit my lip. “I agree,” I simply said. And I did agree. I could rationalize a few elements in a cost analysis, but like Ben, I felt $1,200 was too just too much for the simple test.

Then the obvious question hit me. “Wait, why pay in cash, Ben?” I asked. “Why not have your insurance pick it up?” Ben had a good job with great insurance. Surely the insurer would cover at least part of the tab.

“I’ve not met my deductible yet this year,” he explained in a dreary voice. “I already called them and would be on the hook for about four hundred, even with insurance.”

That was a mere third of what Ben had been quoted if he paid out-of-pocket, so I didn’t see why he was still reluctant to have the sonogram. Ben explained that his budget was tight and even $400 was a lot for him. When Ben and his wife had a baby several months prior, I had wondered at the time how expensive the couple of weeks in the NICU had been.  Now the pieces came together.

I sighed. I knew where Ben was coming from. Years ago I had avoided the dentist for far too long. Though I saved on a dental plan in the short term, my neglect led to pricey repair work down the road.  It’s natural to want to skimp on care when it’s costly.

Recollecting my thoughts, I explained that while preventative tests may not be cost-effective for large swaths of a population, with his family history and doctor’s recommendation, I thought he should have the test.

***

Several days later I received a phone call from Ben. He had been to the cardiologist and did not have a heart murmur, he explained happily.  But he did learn something very important.

The sonogram showed that part of his heart wall was enlarged.  His doctor surmised that hypertension –elevated blood pressure – was the likely culprit. Since hypertension increases the risk of heart problems, with Ben’s family history, the doctor put Ben on a low dose of blood pressure medicine.  The cheap generic prescription cost Ben only $4 a month at the pharmacy.

I asked Ben how he felt about the outcome.

“Honestly,” he said, “I am relieved to know what’s going on with my health.” He sighed.

“That four hundred dollars was a lot, but it may have saved or lengthened my life,” he said in a serious tone. “And, for the price of just four dollars each month,” he said more lightly, “now I’ll be around for even longer.”

I thought of my friend and his new baby. And I smiled.

“Yes, you will, Ben,” I said. “Yes, you will.”

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Josh Trent from Maryland was a contestant in the 2012 Costs of Care Essay Contest.

I had been laid off a few months when my ulcerative colitis kicked in, and my doctor and I struggled to get it under control.  After trying a variety of medicines, my health continued to deteriorate and I agreed to take Remicade.  Remicade is a potent drug, administered through an IV infusion at the oncology center that comes with a whole host of potential side effects.  The dosage requires an initial cycle of 4 infusions spaced several weeks apart, then a maintenance dosage every 8 weeks thereafter.  The decision was not taken lightly.

I was very worried about both the side effects and the cost of the drug, although I was so sick at the time, that I was more worried about whether the drug would bring me quick relief.  I did make a feeble attempt to find out if Remicade was covered under my husband’s and my insurance plan.  After several phone calls where I was transferred around, and several hours of searching through the Blue Cross documentation on line and in its services catalog, I gave up.  My logic was that if I couldn’t find anything explicitly stating Remicade was not covered, then it must be a standard service requiring just another copay. I had never had to pay anything more than a copayment for my medical care so far, and I was hopeful that the charges would again be minimal.

I then spent days searching the internet to learn more about the medicine, potential reactions I could experience, and for patient forums to better understand what I might be facing.  Many of the people mentioned the high cost of the drug.  Even though I tried to ignore these comments, deep down I was very nervous that we would end up with a large medical bill just when we were reassessing our finances.

I had already had my first three infusions before I got my first explanation of benefits – and by then I was well on the road to recovery and I was not about to give up my “wonder drug.”  I was caught completely off guard, however, when I saw that the cost of the medicine alone was $12,000. The insurance company negotiated the cost down by almost half, and when all was said and done, my out-of-pocket was nearly $1,500.  Already, I was fast approaching $5,000 in medical expenses, and I still had several more treatments scheduled for the rest of the year.

My husband and I pored through our insurance paperwork and discovered that our yearly out-of-pocket caps at $5,000, after which time all other costs are covered by Blue Cross for the remainder of the year.  I started to feel better knowing that we would not have to pay more than $5,000.  But I was still distressed to know that this medicine was so expensive.

I immediately contacted the hospital and requested an itemized bill to ensure that all charges were correct.  The items charged seemed valid to me so there wasn’t anything I could dispute.

I vaguely remembered reading something in one of the patient forums about a financial assistance program that would help with the cost of the medicine.  I went back to surfing the internet and I found the pharmaceutical company’s Remistart program through which a portion of a patient’s out-of-pocket expenses could be reimbursed.

I was accepted into the program, and I was ecstatic to learn that I would get a rebate for nearly half of my total out-of-pocket charges.  That was nearly four years ago, and today I am still receiving Remicade treatments, and I am still covered through the Remistart program.

Two years ago my dosage for the medicine was doubled and, not surprisingly, the cost of the medicine doubled as well to nearly $25,000 per treatment.   I asked the Remistart representative if they had an idea of the cost of treatment at the different hospitals. The person reported that the costs are negotiated between the hospitals and the insurance companies, and the company did not have that information.

I have since learned that financial assistance is available through other companies as well.  This information is something that physicians should let their patients know about.  The programs can mean the difference between receiving the drug and not.

I am grateful for this program, but I still worry about the high cost of the medicine. And each year I cross my fingers that the Remistart program continues, and again accepts me into the program.

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Nancy Meredith is a patient in Wake Forest, NC and was a contestant in the 2012 Costs of Care Essay Contest.

By Neel Shah, MD, Christopher Moriates, MD, and Vineet Arora of Costs of Care.

At a time when one in three Americans report difficulty paying medical bills, up to $750 billion is being spent on care that does not help patients become healthier. Although physicians are routinely required to manage expensive resources, traditional medical training offers few opportunities to learn how to deliver the highest quality care at the lowest possible cost. While the gap is glaring the problem is not new.

Neel Shah, MD, is a chief resident in obstetrics and gynecology at Massachusetts General Hospital and Brigham & Women’s Hospital in Boston, MA. He is also the founder and executive director of Costs of Care, a grant-funded 501c3 venture. He can be reached at neel@costsofcare.org. 

Christopher Moriates, MD is a Clinical Instructor in the Division of Hospital Medicine at the University of California San Francisco (UCSF). He is currently Co-Chair of the UCSF DHM High Value Care committee. During residency training he co-created a cost awareness curriculum for residents at UCSF. 

Vineet Arora, MD is an associate professor of medicine and Assistant Dean for Scholarship and Discovery at the University of Chicago Pritzker School of Medicine. She is also Director of Education Initiatives at Costs of Care. 

There’s no way to address long term financial health in the U.S. without including Medicare savings in the mix.  But political action has been stymied by fear among politicians that we over 65ers will rebel against any and every proposal to contain Medicare costs.

The politicians’ fears aren’t unfounded. With out-of-pocket health care costs rising even for well-insured Medicare recipients, it’s not irrational for over 65ers to see proposals for cost containment as stealth proposals for us to pay even more for our care than we do at present or to suffer from loss of important components of medical care. But this “lose/lose” perspective on our part overlooks emerging findings about the amount of “waste” in U.S. health care and the harms we over 65ers experience from overtreatment. As Berwick and Hackbarth argued in a 2012 JAMA article, the lowest estimate of health care waste is 20 percent! In other words, there’s substantial opportunity for Medicare savings without (a) increasing out-of-pocket cost for Medicare beneficiaries, (b) reducing quality of care, or (c) further impoverishing future generations.

In order to focus attention on reducing waste and overtreatment, over 65ers who understand the potential for this “win/win” form of Medicare cost containment need to speak out. Political dialogue has been so dominated by “death panel” and “don’t let the government get hold of my Medicare” fears that we won’t get anywhere with regard reducing waste and overtreatment without a voice from the over 65 population on behalf of clinically informed, ethically justifiable Medicare reform.

I’ve recently joined with a group of young physicians and nurses who embrace the economic and ethical imperative for health professionals to help contain health care costs in a responsible manner. Costs of Care, a 501c3 nonprofit started by medical students and residents is a leading voice in this effort. Its three goals are exactly on target for what the U.S. health system needs:

• ADVOCATE: creating a culture where caregivers are responsible for the cost and value of their decisions, take action to avoid waste, and help build the will for change
• EDUCATE: giving caregivers the knowledge and skills they need to make cost-conscious, high-value decisions with their patients
• SUPPORT: helping caregivers to deflate medical bills by using information technology and decision-support tools to put cost and quality information at their fingertips at the critical moment when medical decisions are made

We launched Over 65 to create a vehicle through which over 65ers could contribute to public deliberation about meeting the health and economic needs of the over 65 population in ways that consider intergenerational equity and the future well-being of our society. It’s heartening to see young physicians and nurses dedicating themselves to this same effort. Collaboration between over 65ers and thoughtful young activists could play a significant role in health system reform. We at Over 65 and my young colleagues at Costs of Care would love to hear your ideas on where savings could take place. Our plan is to publish relevant posts on both sites. I invite Over 65 readers who would like to participate in this collaboration to let me know via email.

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Jim’s post begins a collaboration between Costs of Care and Over 65.

Read the full report here: http://www.costsofcare.org/wp-content/uploads/2013/03/Berger-Price-Transparency-White-Paper.pdf

So why is it that we as consumers know considerably more about the prices and quality of the cars that we purchase than we do of the life saving medical procedures that we undergo? Why is it that we can pay $800 for a colonoscopy at one hospital, and $1,500 for a colonoscopy at a different facility down the road, both providing the same quality of care? In the wake of Steven Brill’s recent Time Magazine cover story, “Bitter Pill,” many have now come to realize that this is the reality that we live in. Patients are overcharged and shielded from the true prices of their care. Hospitals, insurance companies, and the like have historically benefited from patients not asking these important questions, and this has continued for decades.

However, the tables appear to be turning in the healthcare world. An increasing number of workers are being pushed onto high-deductible health plans through their employers. As a result, a growing population of patients is now becoming more price sensitive, but are quickly realizing that the resources don’t exist for them to make such informed decisions.

While a lot of the work to promote price transparency is being done in the private sector through organizations such as Castlight Health and MD Clarity, I set off to explore the various ways in which the state and federal governments are tackling this issue. I looked to an attempt at the federal level, as well as price transparency provisions in a large cost-containment bill in Massachusetts from 2012. The findings can be read in this white paper.

I recently had the privilege of sitting down with Regina Herzlinger and a group of students for a lunch when she visited Saint Louis University. She spoke of the need for healthcare leaders who are interested in innovation and rejecting the notion that we ought to perpetuate the status quo because that is what we have always known. This couldn’t be more true for the price transparency movement in healthcare. Patients play an immeasurable role in the demand for greater price transparency information, but it is going to take innovative leaders in government and healthcare organizations to truly change the way healthcare operates and disseminates this information.

Maybe most importantly, more transparent price information in healthcare has the ability to forge a new relationship between the physician and patient. When both parties have readily available price information at their disposal, it allows for more effective discussions concerning the costs of care, and even greater ability to deflate the medical bills that we have all come to dread receiving.

Read the full report here: 

http://www.costsofcare.org/wp-content/uploads/2013/03/Berger-Price-Transparency-White-Paper.pdf 

While I am currently a second year medical student, my story is one of a sister.

When I was six years old, my mother asked me a question that would forever change my childhood- “Honey, would you be alright with having a foster child join our family? It would mean a little boy coming to live with us for a while.” My response did not take much thought; how could I refuse a new playmate? His name was John, and he was 4 years old to the day when he arrived at our home. Before I knew it, it was as if he had always been part of the family. Through many games of pretend African safari, a family vacation to Disney World, and endless days at school, he became my playmate, my friend, and, as far as I was concerned, my brother.

Without going into the details of his past, it is safe to say that John had dealt with far more emotional and physical trauma than any person, much less a child, should ever face. Like many children with a challenging background, John frequently found himself in trouble at school for lack of focus and rowdy behavior. After several parent-teacher conferences and conversations with the principle, the social worker and my parents agreed that John needed extra help. They decided to have him see a psychiatrist for counseling and treatment. The hope was that this physician could help John learn to deal with and accept his past as well as address some of the current issues he was facing in class.

The medical scenario we faced was not one of great logistical complexity. It required no x-rays, no CT scans, not even a minor surgery. Not a single biopsy or blood culture was needed. All we wanted was a doctor to work with John, address any psychological illnesses he may have been dealing with as a result of his past, and treat him to the best of his or her ability. Such a request would be simple and quite financially feasible to fill for a small child, would it not?

As many of John’s expenses were paid by the government to help cover the cost of his care, his health insurance was accordingly provided by Medicaid. Without this coverage, it would have been a considerable strain on my family to afford his costs in addition to my family’s medical costs, so my mother set to work to find a Medicaid-friendly physician. Running through a large yellow phonebook, my mom worked through physicians in the D.C area. Call after call, she was rejected. Time after time, she heard the same response- “sorry ma’am, but we do not accept Medicaid or new Medicaid patients”. When we finally found a doctor willing to see him, the “therapy” was short-lived. It turned out that this un-named doctor would see John for 5 minutes, increase his prescription for Ritalin he had started him on, and then move on to his other patients while charging Medicaid for an hour-long appointment.

Whether they had denied my brother or mistreated him, my then seven-year-old self hated those doctors, every single one of them. I did not know who they were or how talented they may or may not have been. I did not I understand the difficulty of their situation as physicians, facing their first years out of residency with over 100,000 dollars in debt, the complexity of the health care payment system, or the role of health insurance. I didn’t care about any of their reasons; I cared about John.

Regardless of political agenda or economic ideals, the goal of any health care provider, any sister, any person, is really quite simple- for their patients or loved ones be well. The cost for this medical care goes far beyond dollars and cents. Ultimately, it is the price one pays for access to care and thus for health, productivity, and years of life.

I am thankful to report that John’s story has a happy ending. He has continued on to beat the odds and is now attending college with a bright and full future ahead of him. However, his story is the exception. Every day I spend shadowing in clinic reveals the struggles so many families face in managing their medical payments. Whether it is taking half-doses of medications or avoiding appointments altogether because of the bills, the true cost of care for their lives becomes strikingly clear in their declining health.