Why are free clinics necessary and what role do they play in the provision of health care in the US. The answer is presented in the book’s foreward:
In 2011, 46.3 million people were uninsured in the United States, about 15% of the population) This figure was expected to rise by the end of 2012. For minorities, the figures are worse, with nearly 30% of Hispanics and nearly 20% of African Americans being uninsured) Free clinics receive nearly 4 million patient visits a year. Without these clinics, the nation’s emergency departments and public health clinics (including federally qualified community health centers) would have to absorb all these patients and the costs associated with their care.
Simply put, free clinics provide an enormous amount of care. Even after the full implementation of the Affordable Care Act it is estimated that 20 million plus people will be without health insurance in the US. Many millions more will be under-insured meaning that the cost of actually using their insurance will be prohibitive. Thus, “free clinics” stand as a reminder of the failure of our society to guarantee health care as a human right. They also demonstrate the enormous commitment of many health care professionals to caring for people even when not paid.
Since the chapters come from an academic journal there is focus on critical thinking and data-driven evaluation. This is not a coffee table book idealizing the people who provide free care. There is, for instance, discussion of the “stop-gap” and “band-aid” nature of free clinics. Half of the book is devoted to general experiences with free clinics and the other half is devoted to papers on student-run free clinics. The book will be particularly valuable for those involved with (or thinking of setting up) free clinics.
Free clinics should not really be needed. Yet for those of us working in primary care the problems of un-insurance or under-insurance (particularly in working-class immigrant communities) is a daily reality. We work at and we refer to free clinics because we must. But all the while we remember that in the great towers of Wall Street – the banks, the insurance companies, the brokers – there is the money to set this problem right.
*Paraguayan 5th year student participating in primary care in Havana, Cuba. (2011,by Joanna Mae Souers)
In early 2007, I began studying medicine at the Latin American School of Medicine in Havana, Cuba. I entered the program not knowing much about the Cuban healthcare system, other than that it was universal and free. “Now that’s a system I want to learn from,” I thought to myself, “It’s a system we could all learn from.” Five years later, what have I learned?
There are many subtle and not so subtle differences between the Cuban and the U.S. health care systems which have allowed the Cubans to equal the U.S. with respect to their health statistics, but at a much lower cost and with better preventative and primary care. In this paper I analyze just one of the reasons for the differences between the two systems; Cuba produces more primary care practitioners per capita. How do they do it? Medical education in Cuba is free, all doctors interested in specializing must first serve two years working in primary care, and graduating doctors are not driven to specialize by salary incentives. This socialist approach towards medicine and medical education assures the human resources necessary to provide universal and preventative healthcare to all.
People marvel at how Cuba has “accomplished so much with so little.” And they marvel with good reason. According to the World Health Organization, Cuba spent only $503 per capita on healthcare in 2009, the U.S. spent almost 15 times that sum. In fact we in the US spent $421 per person just on the administration of the private healthcare insurance system, almost enough to fund the Cuban system.  Despite dramatically lower costs, Cuba has some of the best health statistics and health indicators of any country around the world.
Although people like to compare and contrast the health statistics of the U.S. and Cuba, I think this a bit preposterous. Cuba, a small island in the Caribbean, is being compared to one of the largest countries in the Americas with a very different history. So in the table below, I have shown some health statistics on Cuba and the U.S. as well as the Dominican Republic and Haiti. The Dominican Republic and Haiti are Cuba’s Caribbean neighbors; similar in size, history and geographic location.
*Statistical information provided by the World Health Statistics 2011 Report by the World Health Organization.
From this table, we can see that Cuba’s health indicators are more like those of the “first world” in the U.S. than its neighbors in the “third world.” The life expectancy of the U.S. and Cuba is almost identical. Cuba supersedes the U.S. in the categories highlighted. So we continue to ask, “How do they do it?” Could it have something to do with their philosophy that people need doctors? Hence, their solution is to offer a free medical education to develop young, quality doctors dedicated to serving those in need.
Per capita Cuba graduates roughly three times the number of doctors as the U.S. In 2005 Cuba had 70,594 doctors. Before the revolution in 1959, there were only an estimated 6,000 doctors; somewhere around half left the country after 1959. This means they must have graduated an average of 1,469 Cuban doctors per year, not including the some 5,000 international students who graduate each year from Cuban medical schools.  When we later compare these numbers to the U.S. we see that Cuba graduates 3 times the number of doctors per capita, and the U.S. must import graduating doctors from other countries just to fill the primary care residency positions.
Critics of the “Obama Plan” say that there will not be enough doctors in the U.S. to take care of all the patients if everyone has healthcare coverage. Obama encouraged the Association of American Medical Colleges to increase the number of graduating doctors by 30% in 2010. Ever since 1980, U.S. Medical schools have graduated 16,000 doctors a year. Meanwhile, the population of the U.S. has grown 50 million during the same period. A 30% increase would have meant we should have graduated 20,800 medical students in 2010, but we only graduated 16,838 according to the Kaiser Family Foundation. The number of residency programs at teaching hospitals in the U.S. has been frozen since 1997, funded by Medicare. There were 29,890 residency slots filled in 2009,positions not filled by American graduates are filled by International Medical Graduates.  This means we can estimate more than 1/3 of students in U.S. residency programs are International Medical Graduates (IMGs), students from another country or a U.S. citizen, like me, who studied in another country.
In the current scheme of things, International Medical Graduates are continuously brought in to the U.S. to meet the needs of the growing patient population. Unfortunately nothing bridges the gap, because there just are not enough residency positions and/or funding for teaching hospitals to produce enough doctors to satisfy the entire U.S. population. Taking International Medical Graduates to meet the needs of the U.S. population only adds to the “brain drain” of developing countries around the world. So as we produce fewer doctors, introduce more doctors from other countries; U.S. doctors work harder for less to meet the needs in the U.S. and a lot of the world remains catastrophically underserved.
Cuba leads the world with the lowest patient to doctor ratio, 155:1, while the U.S. trails way behind at 396:1. With a surplus of Cuban doctors, Cuba is able to help ailing nations around the world. They have medical missions in over 75 different countries lead by nearly 40,000 health professionals, almost half of them are doctors. The United States by contrast imports doctors from poorer countries, further contributing to the brain drain of professionals from poorer countries to rich ones.
In Cuba education is free. Room and board, books and amenities are included. Doctors are not burdened by student loans and live comfortably though not extravagantly. Harvard Medical School states in their admissions statement that an “un-married first year medical student” will spend approximately $73,000 for the 2011-2012 academic year. This includes tuition, room and board, books, etc. Now times that by four and you have a whopping $292,000 to shell out to become a Harvard doctor. With interest rates, loan deferments and default charges, you might end up like Michelle Bisutti. She graduated medical school in 2003 with a $250,000 debt, in which by 2010 had increased to $555,000. This may be an extreme case, but the Association of American Medical Colleges projected in their 2007 report that in 2033, students on a 10-year repayment program will only see half of their after-taxes salaries, the rest going to loan repayment.
The cost of medical education in the U.S. causes more and more medical school graduates to turn to higher paying specialties and subspecialties rather than primary care or family medicine. Dr. Thomas Bodenheimer writing for the New England Journal of Medicine, stated that “between 1997 and 2005, the number of U.S. graduates entering family practice residencies dropped by 50 percent,” based on data from the National Resident Matching Program.  In the U.S. specialists predominate at a ratio of 2:1 (the reverse of other Western countries) while half of all outpatient visits are made by primary care physicians.  This deficit of primary care physicians decreases people’s access to primary care and preventative medicine, causing increases in health disparities and healthcare costs. This is because preventative medicine benefits the patient as well as reduces the number of Emergency Department visits and hospital stays. If there are no primary care physicians to provide preventative care to the population, we see the population suffer as costs continue to rise.
* Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates. From the American Academy of Family Physicians, based on data from the National Resident Matching Program. 
According to a survey in 2008 by the American Academy of Family Physicians, family medicine graduates with less than 7 years of experience earn, on average, a yearly salary of $145,000. The difference in earnings between primary care physicians and specialists differed by only 30 percent in 1980, and dramatically rose up to 300 percent for some narrowly defined specialists by 2009. In the graph below, we show the dramatic difference between median compensation for selected specialties compared to that of primary care.[14,15]
*Median Compensation for Selected Medical Specialties. Data are from the Medical Group Management Association Physician Compensation and Production Survey, 1998 and 2005. 
When working in the U.S., almost every primary care physician I talk to has the same complaint, “Too many patients, and too little time.” They are forced to see 20 to 30 patients a day just to meet pay-incentives and “keep their doors open.” General/Family Practice physicians spend an average of 16.1 minutes with each patient per visit.  Meanwhile, 18%, or roughly 48.2 million of the U.S. population under the age of 64 is without healthcare insurance. They have no access to most GP’s or family practice physicians. 
We need to follow our Cuban role model, we need to be held socially accountable and produce more primary care physicians. This can be accomplished by providing an education at full scholarship to those interested in primary care, or by increasing the number of medical students going into primary care by closing the compensation gap between primary care and the higher paid specialties. These measures would ensure the population better access to quality primary care and preventative medicine. It would bring down the cost of healthcare while allowing primary care physicians to practice under less stressful conditions leading to quality affordable healthcare for all.
World Health Organization (WHO 2011); Countries. [www.who.int/countries/en]
“Healthcare Marketplace Project, Trends and Indicators in the Changing Marketplace (Exhibit 6.11: Private Health Insurance Admin Cost per Person Covered, 1986-2003),” Kaiser Family Foundation, Publication Number: 7031. [http://www.kff.org/insurance/7031/print-sec6.cfm]
“Cuba and the Global Health Workforce: Training Human Resources.” Salud! (Source Vice Ministery for Medical Education and Research, Ministry of Public Health) [http://www.saludthefilm.net/ns/elam.html]
Sullivan, Paul. “Discomfort at U.S. Medical Schools.” The New York Times; April 29, 2009.
“Total Number of Medical School Graduates, 2010.” The Kaiser Family Foundation. [http://www.statehealthfacts.org/comparemaptable.jsp?ind=434&cat=8]
“World Health Statistics 2011,” World Health Organization; WHO Press, Switzerland.
Brouwer, Steve. “The Cuban Revolutionary Doctor: The Ultimate Weapon of Solidarity,” Monthly Review, 2009, vol 60, issue 8 (January).
Harvard Medical School Admissions, “Costs (Updated: 7/21/2011).” [http://hms.harvard.edu/admissions/default.asp?page=costs]
Pilon, Mary. “The $555,000 Student Loan Burden,” The Wall Street Journal, February 13, 2010.
Fuchs, Elissa. “With Debt on the Rise, Students Face an Uphill Battle.” The Association of American Medical Colleges, January 2008.
Bodenheimer, Dr. Thomas,“Primary Care – Will it Survive?” New England Journal of Medicine, vol 355;9. Pg 861-862.
Alper, Philip R. “Primary Care’s Dim Prognosis,” Hoover Institution, Stanford University, Policy Review No. 158 (December 1, 2009).
American Academy of Family Physicians, Income (2011). [http://www.aafp.org/online/en/home/publications/otherpubs/debtmgmt/graduation/income.html]
Alper, Philip R. “The Decline of the Family Doctor,” Hoover Institution, Stanford University, Policy Review No. 124 (April 1, 2004).
Woo, Dr. Beverly. “Primary Care – The Best Job in Medicine?” New England Journal of Medicine, vol 355;9. Pgs 864-866.
“Healthcare Marketplace Project , Trends and Indicators in Changing Healthcare Marketplace (Exhibit 6.5: Mean Time Spent with Physicians (in Minutes), 1989 – 2002),” Kaiser Family Foundation, Publication Number: 7031, Information Updated: 4/11/05. [http://www.kff.org/insurance/7031/print-sec6.cfm]
“2010 National Health Interview Survey (Tables 1.1A-B, 1.2 B)”, Center for Disease Control. [http://www.cdc.gov/nchs/fastats/hinsure.htm]
Junot Diaz returns to Columbia University in A Night with Junot Diaz: Una Lectura y Conversacion on Saturday, November 6, 8:00 – 10:00 pm. The event will take place at Alumni Auditorium and doors open at 7:30 pm.
CoSMO is the free-clinic run by Columbia Medical Students, one of a number of such clinics run by medical students in New York City (see our series on free and low-cost health care). Two years ago, the clinic was fortunate enough to have Junot Diaz, the Pulitzer Prize-winning author of “The Brief Wondrous Life of Oscar Wao” read from his works in a benefit performance. The show was a sold-out and the auditorium packed. Now Junot Diaz returns to read and discuss the immigrant experience in the US and minority treatment in the US health care system. The reading will be followed by a question and answer session.
We reproduce below an announcement from the NYU College of Dentistry about free dental screenings next week. Readers who are interested in additional resources for free and low cost dental care should consult the HITE website, which probably provides the best listing of resources in the city. You can also check out a complete list of our postings about free and low cost resources.
Join NYU College of Dentistry and ABC7 in celebrating the 25th anniversary of free health screenings in NYC. Free dental screenings will be available on March 30th, March 31st, and April 1st (spring break*), at the NYU College of Dentistry, 345 E. 24th Street (corner of First Avenue) from 8:30 am -7:00 pm.
All children ages 6 months to 10 years will receive a cute, cuddly “healthy smiles” teddy bear commemorating their visit. Adults and children will receive free dental screenings and vouchers for free oral examinations and polishings. Vouchers for free dental sealants will be provided for children, as well as for free custom-made mouth guards for young athletes. Free diabetes and blood pressure screenings will take place, as well as free oral cancer screenings for adults. Visitors will also receive free toothbrushes and other personal oral hygiene products.
WHO: NYU College of Dentistry and ABC7 WHAT: Free dental and oral cancer screenings, diabetes and blood pressure screenings
Vouchers for free oral examinations, sealants and custom-made mouth guards
Free toothbrushes and other oral hygiene products WHERE: NYU College of Dentistry, 345 E. 24th Street (corner of First Avenue) WHEN: Tuesday, Wednesday, and Thursday, March 30, March 31, and April 1, 8:30 am – 7 pm.
No appointment necessary. For more information, call 1-866-698-0264. And be sure to watch the Accu-weather forecast on ABC7 at 5:00 pm and 6:00 pm during the week of March 29th. For more information about the NYU College of Dentistry, please go to www.nyu.edu/dental.
For several years, Manhattan’s Swedish Institute (226 W 26th St.) was the place to go for low-cost acupuncture treatment in New York City. The Institute’s teaching clinics offer both acupuncture and Swedish massage. A 13 week course of acupuncture cost $360 ($150 for seniors).
A recent article in The Teaching Physician (a publication of the Society of Teachers of Family Medicine) discussed a new (free) initiative to make it easier for people to both make – and retrieve – advanced directives. “Information Technology and Teaching in the Office: Advance Directives Online” by Richard P. Usatine, MD, and Craig M. Klugman, PhD, University of Texas Health Science Center at San Antonio was published in the October 2009 edition and discusses Caring Connections (http://www.caringinfo.org/).
Caring Connections was developed by the National Hospice and Palliative Care Organization (NHPCO) with support from the Robert Wood Johnson Foundation. The website offers a number of resources for people considering end-of-life care. The one highlighted in the article was the ability to create and store advanced directives on line.
As noted on the site: “Advance directives allow you to document your end-of-life wishes in the event that you are terminally ill and unable to talk or communicate. ” They generally take two forms. In a living will someone specifies what kind of care he or she would like in future. A health care proxy is someone who can make decisions for a patient if he or she is incapacitated.
As a practicing clinician I find that there are several problems with Advanced Directives. First, people don’t fill them out. No one likes to think about their own death. Second, people often turn to lawyers who charge money to complete these forms. This is really not necessary. The forms in New York State can easily be completed by a family. [The specifics of advanced directives, however, vary by state.] Finally, there’s no logical, single place to put Advanced Directives so that they are easily retrievable in an emergency.
The Caring Connections site deals with both problems. State specific forms are available for downloading. The forms come with very detailed instructions. Once they have been completed users are encouraged to scan them and upload them to a Google Health Profile. This profile can then be shared with the key people who need access to the advanced directives.
One is always a bit reluctant to further promote the Google monopoly on the web, but this is a useful free service. It is, however, only available in English, a true limitation in an ever more diverse United States.
Last Tuesday’s Social Medicine Rounds (9/8/2009) was prompted by the brutal murder of family physician George Tiller on Sunday May 31st 2009. While serving as an usher at the Reformation Lutheran Church in Wichita, Dr. Tiller was shot in the head and killed. We convened this Rounds to consider how we might respond to his death. Two issues dominated the discussion. The first was the failure of the American Academy of Family Physicians (AAFP) to condemn the murder. The second was an examination of the ongoing barriers to abortion care that exist even in a relatively progressive state such as New York. These problems were illustrated through 3 case vignettes.
In July of 1970, I planned to start a dermatology residency. On August 21, 1970, my father, mother, sister and brother-in-law were killed in an aircraft accident. My sister had a 12-month-old boy, Maurice. They had written out a will in longhand the evening before the airplane crash, that I was to raise Maurice. So we took charge of my sister’s boy and we moved back to Wichita. My game plan was to spend six months here, close out my father’s huge family medicine practice.
After I had been there for a little while, patients in the practice began to ask me if I was going to do abortions like my father did. I was outraged. Why would these nice people say that he was a scumbag kind of a physician?
I began to ask some of these women. And I found out that in 1945, ’46, or ’47, a young woman for whom Dad had already delivered two babies came to him pregnant again right away, and she said something to the effect that, “I can’t take it, can you help me?” That is apparently the way you asked for an abortion from your regular doctor before abortion was legal. Dad said, “No. Big families are in vogue, by the time the baby gets here, everything will be all right.” She had a non-healthcare provider abortion and came back and died.
I can understand how upset my father was. I do not know whether he did 100 abortions or 200 abortions or 300 abortions. I think it may have been something like 200 over a period of about 20 years, but I don’t know for sure. The women in my father’s practice for whom he did abortions educated me and taught me that abortion is about women’s hopes, dreams, potential, the rest of their lives. Abortion is a matter of survival for women.
When it became legal and my patients began to ask for it, I’d say, “Sure. It’s a legal process.” I was a service provider. I was a physician. The patients needed abortions, and I did them. It is my fundamental philosophy that patients are emotionally, mentally, morally, spiritually and physically competent to struggle with complex health issues and come to decisions that are appropriate for them.
We’ve been picketed since 1975. My office has been blown up. In 1993, I survived an assassination attempt. My kids were harassed in high school. I had to write letters of complaint to the City Council and the Board of Education. We had people who actually camped across the street from our house. I restrict where I go to eat, where I travel. You see a car following you, you think, “Ah-ha, let’s watch that.” You’re always on alert. You’re always looking around.
I was leaving the office. It was 7:00 in the evening. As I’m driving out, I have to slow down and I have to stop. Bang, bang, bang, bang, bang, bang, and I thought to myself, “That lady is shooting me with rubber bullets. I’m not afraid of rubber bullets.” Then I looked down and all this blood is all over the place. I thought, “She shot me. She can’t do that! I’ll get her.” I saw her running through some front yards. So I zipped down the street, turned in front of her to block her escape. She stops and reaches into this little fanny pack that she’s wearing in the front, and I thought, “She’s going for her gun again. She shot you once, George. She’ll shoot you again. You are in the wrong place at the wrong time.”
So then I drove off. Ended up back at the office, and I don’t remember anything for about 20 minutes. I remember trying to get into my car and drive myself to the hospital. I said, “Let’s not make this a big media event.” Well, I had lost 20 minutes and the TV trucks were there. I thought, “How’d they’d get here so soon?”
There was never any question in my mind that I was going back to work the next day. I belonged there and they were not going to separate me from my job and they were not going to separate me from my community. So I did go to work the next day, and we got everything done. People got taken care of, it took a long time. Arms hurt, bled a little bit, but so what? I am not going to be run over and I’m not going to run out. It’s just that simple.
I am a member of this community. Our DNA has been here since 1880. I belong here. The folks that come in from out of town, they are the intruders. Forty percent of all the people who were arrested here during the Operation Rescue in 1991 came from out of state. I intend to stay here. I am part of the fabric of Kansas and Kansas is part of the fabric of me.
I have more to be grateful for than I have to be resentful about. We have much more support in Wichita than we have rejection and castigation. If Wichita and our community did not want us to be here, I wouldn’t be here. But the vast majority of people in Wichita support, on a quiet level, what we do, which is help women and families.
Extensive coverage of the murder can be seen in this June 1, 2009 broadcast of Democracy Now. This program includes an excerpt from a 2008 speech Dr. Tiller gave to the Feminist Majority Foundation in which he explained his social vision: “We’ve given war, pestilence, hate, greed, judgment, ego, self-sufficiency a good try, and it failed. We need a new paradigm that consists of kindness, courtesy, justice, love and respect in all our relationships.”
Non-Response of the American Academy of Family Physicians
Tiller’s death was clearly not a random act of violence. As noted by Colorado physician Dr. Warren Hern:
I think it’s the inevitable consequence of more than 35 years of constant anti-abortion terrorism, harassment and violence. George is the fifth American doctor to be assassinated. I get messages from these people saying, ‘Don’t bother wearing a bulletproof vest, we’re going for a head shot.’
The American College of Obstetricians and Gynecologists (ACOG) finds the murder of George Tiller, MD, deplorable and tragic. There is no excuse, no explanation, and no justification for this brutal slaying of a courageous and honorable physician who provided safe and legal reproductive health care to women who otherwise might not have received it. It is especially chilling and deeply disturbing that this violence has occurred at a time when the leaders of this country are committed to finding a common ground in the abortion debate.
ACOG extends its sympathy to the family of this dedicated physician who treated his patients with dignity and compassion.
As ACOG expressed in response to the 1998 murder of Dr. Barnett A. Slepian, “With each new incident of anti-abortion violence, the previously unthinkable becomes commonplace—that vandalism could turn to murder, that slayings could move from the clinic to inside the home.” The murder of Dr. George Tiller is even more horrific in that he was killed in a house of worship as he and his family attended church services.
There is no common ground when it comes to violence of this nature. All groups in the abortion debate, whatever their personal opinion on abortion, must condemn such brutality in the strongest possible terms. Failure to make such condemnation is acquiescence to violence and intimidation. Only by standing together can we ensure that acts of brutality end.
The fundamental tenet of the pro-life movement is that human life has intrinsic value and is deserving of protection from the moment the seed and egg unite, until natural death. To take a life without due process devalues all life.
We at Operation Rescue were shocked to hear of the killing of late-term abortionist George Tiller and were among the first groups to denounce the cowardly act that took Tiller’s life. It was not justice, but vigilantism, which must be abhorred by a society that embraces the rule of law over anarchy.
With even the anti-abortion movement condemning the murder, how odd it seems that the American Academy of Family Physicians (Working for Family Medicine, Working for You), of which Tiller was a member, refused to issue a statement. A strongly critical commentary by Dr. Joshua Freeman (The Murder of George Tiller – Where is Family Medicine’s Response) in this month’s Family Medicine explored the reasons cited by the Academy for this refusal. The AAFP pointed to a policy that it “does not comment publicly on a member’s death (regardless of how it occurred) but expresses condolences privately to the family.” Of course George Tiller did not merely die. He was murdered. He was not simply murdered. He was assassinatedfor carrying out his duties as a physician. One cannot help but remember the comments of ACOG:
All groups in the abortion debate, whatever their personal opinion on abortion, must condemn such brutality in the strongest possible terms. Failure to make such condemnation is acquiescence to violence and intimidation.
Barriers to Abortion Access in New York: 3 case studies
We then considered three case scenarios illustrating the barriers to abortion access in New York State. Each case came with a series of discussion points. One point, considered in each of the cases, was the role of abortion in current health care reform proposals. (All identifying information has been removed or altered in these cases).
Case 1: Teresa is a 22 year old woman, G1P1, who comes to your office for a refill of her Nuva-Ring. She reports that she had actually run out 4 weeks ago, but couldn’t afford the time off from work at the Post Office to get in any sooner. She had unprotected sex 2 weeks ago. Her pregnancy test is now positive. Teresa is sure she cannot afford to have another baby right now. She decides with you to have an abortion. You give her the number to call Planned Parenthood to schedule it, and she calls you back later to tell you her insurance does not cover the procedure because she is a federal employee.
The Hyde Amendment bans the use of federal funds for abortions except in cases of life endangerment, rape or incest.
In addition, 32 states and the District of Columbia have prohibited the use of their state Medicaid funds for abortions except in limited cases allowed under the Amendment.
What is your role as her primary care doctor in facilitating her timely access to abortion care?
What are the implications for a universal federal health plan?
Case 2: Angela is a 31 year old woman G6P4, who works as a babysitter “off the books,” and comes to your office because she is pregnant and wants an abortion. You know that she has Medicaid so you refer her to the local abortion clinic for care. She calls you the next day to tell you she was denied care because her insurance does not cover abortion. You are confused because in New York Medicaid does cover abortion, so you call the clinic. They tell you that your patient has Fidelis (a Catholic HMO) and Fidelis does not cover abortion care.
What is your role as her primary care doctor in facilitating her timely access to abortion care?
What happens with Medicaid HMO’s that are “owned” by the Catholic Church?
What does this mean about how our tax dollars are being spent?
Can Angela use her Medicaid to pay for her abortion?
Would she be covered by a federal health plan?
Case 3: Monica is a 16 year old woman, G0P0, currently attending Roosevelt High School. She was sent to you by her school-based health center because she had a positive pregnancy test. Monica’s parents have insurance, but she does not want them to know that she is pregnant. After talking to you, she decides she would like an abortion. But she stresses the importance of not letting her parents find out. She tells you that last year her 18 year old sister got pregnant and they kicked her out of the house.
What are the rules in New York State regarding confidentiality for teens around pregnancy care?
Can she get other insurance to pay for her abortion?
What are the systems issues around eligibility for Medicaid?
What is your role as her primary care doctor in facilitating her access to abortion care?
Among the most popular posts on the portal have been those in our series on Free and Low Cost Health Care. In this post I would like to emphasize the importance of comparison shopping for medications. Prices for the same medication can vary dramatically from pharmacy to pharmacy. I would like to illustrate this by sharing the story of one of my patients.
An unpleasant experience at CVS
The patient was an 80 year old woman who had just undergone her first round of chemotherapy for cancer. Her physician prescribed Ondansetron, the generic version of Zofran, an anti-nausea drug used primarily in cancer treatment. Ondansetron is generally taken twice a day and the physician prescribed sixty 8 milligram pills in anticipation that the patient would undergo multiple rounds of chemotherapy.
When the patient went to pick up the prescription at her local CVS she was asked to pay $900. When she demurred from what seemed like an excessive price, the pharmacist offered to supply a lesser quantity of pills – 10 for $150. This was still the same price, but a lesser quantity of pills. The patient was informed that all pricing of drugs was done centrally by CVS and that nothing could be done at the store about the price. She left the pharmacy and asked me for assistance.
I checked my Epocrates software and learned that thirty 4mg Ondansetron tablets were available on drugstore.com for about $39.99. The equivalent price for this patient’s prescription (120 4mg tablets) would be $160, not $900. To verify that this was a fair price I called a local pharmacy I use frequently in the Bronx and asked them how much they charged for sixty 8 milligram tablets. I was told that they could sell this for $135, perhaps less if my patient did not have much money. When I mentioned the CVS price of $900 the pharmacist remarked, with a touch of irony, “that’s quite a mark-up.”
The “mark up” in this case meant that CVS charges roughly six times what other pharmacies are charging. I would consider this to be price-gouging (“pricing much higher than is considered reasonable or fair“). It is particularly concerning that the victim of this was a vulnerable elderly patient undergoing her first round of chemotherapy. Fortunately, she was able to get her medicine for considerably less at a pharmacy I recommended.
I wrote to CVS about this case and here is the gist of their reply:
1. CVS’s two primary drug chain competitors charge more for Ondansetron.
Learning that three of the major pharmacy chains all charge six times the going rate for Ondansetron is hardly reassuring. And, as I never tire of repeating to my sons, “the fact that someone else gets away with doing something wrong, doesn’t mean you should do it.”
2. CVS also sells other anti-nausea medicines (notably Prochlorperazine and Promethazine) at considerably less, about $10 for a ninety day prescription.
This may well be true, but what exactly does it mean for my patient? Certainly, CVS cannot suggest that she should have exercised some type of medical judgment that Promethazine (a drug she undoubtedly never heard of) was equivalent to the medicine prescribed by her oncologist. Should she have had the oncologist paged at 6PM to request a cheaper medicine? And what if the oncologist had stated that drugs like Ondansetron are considered among the drugs of choice for chemotherapy related vomiting? (See, for example, The Medical Letter, 12/15-29/2008)
3. Finally, CVS noted that it provided a variety of other services, such as expanded hours and online prescription ordering, that were not offered by its competitors.
Yes, but do such services justify these prices? And will my patient be making an informed choice when she spends the extra $700 plus dollars for the CVS extras?
Let the buyer beware
The most important lesson of this story is that drug prices vary dramatically from store to store. The chain stores are not always the cheapest. And, as many patients learn, you might have better luck bargaining with a local pharmacist.
What are the larger implications of this case?
As the debate over health care reform rages in Washington, it is important to keep in mind the fundamental question we face: Is health care just another commodity (like bricks or toothpaste) or is it a human right?
The social argument for making health care a commodity is based on the idea that market rationality will create an efficient health care system. Individual consumers guided by rational self-interest will make wise choices, rewarding efficient health care suppliers with their patronage and punishing inefficient health care suppliers. Of course, no actually existing health care system is run this way. And there are many ways in which health is not like a commodity. Nonetheless, the belief that rational markets will create efficiency in health care is behind many recent reforms internationally and the current proposals to have insurance companies administer the US health care system.
But a case like that of this patient shows several of the weaknesses of this argument. Having just received her first session of chemotherapy and without any medical expertise, this patient was particularly vulnerable and clearly in no position to make the presumably rational choice of – for example – calling up a variety of pharmacies to ask for alternate prices. Or of calling up her oncologist and querying her oncologist’s medical judgment. Or of deciding that she would prefer more nausea to less money.
Indeed, can there be an economically rational choice with respect to nausea versus money?
It might be argued that the responsibility for economic rationality lies with the physician, not the patient. But in this case the physician had prescribed a generic medication, an economically rational choice. Is one really to expect physicians to know the prices of all the medications they prescribe at all the potential pharmacies their patients visit?
This is a dramatic case, but the issues are similar in less dramatic ones.
Wouldn’t the rational thing be for the government to assure that people get the drugs they need and negotiate real prices with the drug companies? This solution is not without its own set of problems, but surely they are better than what happened to my patient.
And yet the price disparities continue to exist. Perhaps this should be one of Project Censored’s top censored stories. They take nominations at this link.
The patient in this case graciously provided me with permission to share her story. I have no financial interests in any pharmaceutical company or drug store chain. I would not want readers of this column to construe this story as a specific endorsement of drugstore.com. Buyers should beware, always.
This website has a very extensive list of resources. For example, it lists 170 dental providers and 687 clinics. Each listing provides detailed information about the provider, including address, phone, services provided and even links to provider web pages. It is also possible to search for providers by zip code and distance you are willing to travel. The site also has a help phone number: (866) 370-HITE.
Here is a description of the site taken from their FAQ page:
The Health Information Tool for Empowerment (HITE) is the first online directory of health and social services specifically for uninsured and under-insured New Yorkers. With the click of a mouse, HITE allows professionals to link their underserved clients with a broad array of health and support services.
HITE has two components:
Resource Directory. A comprehensive directory containing thousands of national, state, and local organizations and programs available to low-income, under-insured, and uninsured people, as well as links to dozens of Web sites that provide information on everything from how to apply for public health insurance to where you can get free or low-cost medications.
Eligibility Calculator. Eligibility screening tool for public health insurance, private health insurance, and other public benefits programs. HITE links to two screening tools. The NYC Human Resources Administration pre-screening tool helps determine whether their clients meet the basic eligibility requirements for one of New York’s publicly funded health insurance programs: Medicaid, Child Health Plus (CHP), and Family Health Plus (FHP); or for a low-cost private insurance program. ACCESS NYC, sponsored by the City of New York Mayor’s Office screens for eligibility for public health insurance and other public benefits/government entitlements.
Our earlier post had suggested the NYU College of Dentistry Clinic and similar clinics at other dental schools. We also mentioned New York City Department of Health dental clinics for people up to age 21. (Our patient was 23).
If you have no insurance, this is a useful site to visit. It provides a screening tool (it shows up as a sidebar on each page) to help you determine if you might be eligible for any public or private insurance plans.
Finally, – in terms of free non-dental services – this week we learned the NYC DOH offers free condoms and lubricants to organizations that will distribute them for free. Click on this link.
Brush your teeth and floss after each meal, stay away from sweetened drinks and have fun (safely).
As part of our series on free and low cost health care in New York I wanted to share a few resources on free and low cost medicines.
Dr. Brian Alper (a family physician who foundedDYNAMED) has put together a very useful set of clinical links for physicians at: www.myhq.com/public/a/l/alper. Among the many categories in this list are six links to “indigent drug programs.” To test these sites out, I decided to look up Herceptin, an anti-cancer agent made by Genentech. [I was recently asked to find this drug for a medically indigent patient.]
Needy Meds: is a not-for profit “with the mission of helping people who cannot afford medicine or health care costs.” The information at NeedyMeds is available anonymously and free of charge. The most useful part of this website is the listing of drugs – both generics and brand – that are available from patient assistance programs (PAP’s). If you find a drug and a PAP, many of the applications can be downloaded from the website. Most of the links seem to be from 2008. The site also has a link to free clinics. I easily found Herceptin on the Needy Meds site with links to application form in English and Spanish as well as the Genentech website.
Rx Assist is managed by Astra Zeneca and claims to be the “Web’s most current and comprehensive directory of Patient Assistance Programs.” The Rx Assist site has a searchable database so you don’t have to scroll down lists. Herceptin was also easy to find on RxAssist, but the site linked only to the English application and the Genentech site.
Benefits CheckUp is run by the National Council on Aging and is a very different type of site. It provides information on a wide variety of benefits – housing, food, medication, medical care, utilities, “and more.” It works a little bit like an online social worker. To find information on Herceptin (for a fictious patient), I needed to input zip code, age, information about work, income, and assets; this process generally takes 10-15 minutes according to the website. I could easily imagine that it would take much longer if you had to find all the documentation. When this was through, Benefits CheckUp suggested I apply for New York State’s EPIC program (which helps elderly people with prescription costs), New York State Medicaid and also offered the Genentech program. There were links to the Genentech site, application forms, and even a list of documents I would need. Very complete, but a bit daunting in terms of the information I needed to supply.
All three of the above sites linked to a variety of health care resources, not just medications.
Partnership for Prescription Assistance also links to PAP programs. This site required me to enter information (age, location, income, insurance coverage, etc) before leading me to the Genentech site. It did not link directly to the Herceptin application. Unlike the sites listed above PPARx did not provide links to other types of social programs (such as free clinics).
Finally, Dr. Alper’s site links to an August 2004 article in the American Family Physician “Curbside Consultation: When Patients Cannot Afford Their Medications” This is a very thorough review of the topic with – in typical AFP style – lots of useful information. According to the AFP article 5.5 million people were enrolled in PAP programs in 2002.
I would note that – based on my personal experience – the typical patient who needs the PAP’s often times does not have access to the internet nor facility with completing forms. So having someone to be their advocate is crucial. This is a weakness of these websites.
A couple of additional suggestions:
Patients should always check to see if they are overpaying. Do this by looking up the prices of medicines on Drugstore.com. Oftentimes pharmacies charge unreasonable prices (people go, after all, to the local store) and lots of money can be saved by shopping around.
A recent blog from Suite 101.com entitled “How to Find Free, Cheap Drugs” offered (among other information) a list of retailers offering low cost or free medications. These include WalMart, Target, K-Mart, and various food chains. For example, “Publix supermarkets offer free antibiotics if you have a valid prescription, regardless of whether you have health insurance. A 14-day supply is offered.”
Some sites I have seen offer to help patients find low-cost drugs from a small fee. Clearly this is not reasonable since this information is available for free.
As I have noted in previous blogs these various efforts do not solve the root cause of the problem: lack of universal access to healthcare (including medications) in the United States. But for patients in need these resources can be helpful.