Archive for the 'Workers Health' Category
Add a comment June 28th, 2009 by Aaron
The national debate on health reform has uncovered innumerable “health care horror stories” in which cancer patients worry more about their bills than their malignancy or where pregnant women are laid off and dropped from their insurance soon before their due date. These stories are tragic, and unconscionable for the richest country in the world, however, as a physician, this is not my typical experience. Instead, what I see every day is patients with private health insurance who cannot afford the copays for their medications, delays in treatment as I grovel for prior authorization with a non-physician utilization reviewer, and patients stuck with huge bills for routine services that they thought they were covered for.
In my practice, patients have a mix of private and public coverage. While I work with some extremely impoverished patients who qualify for public insurance through Medicaid, it is the people with employee sponsored private insurance who are most at risk for roadblocks to care. As a primary care physician, it is hard enough to fit all of the recommended screening, health education, and chronic disease management that complex patients need into a fifteen minute visit. When the burden of battling with insurance companies is added to the equation, there is no way that I can succeed. My patients, especially the ones with private insurance, are forced to deal with the high copays, denials of claims, and delays in care.
Reflecting on the past week, a bunch of cases come to mind. While these stories may lack drama, it is nonetheless troubling to me how frequently my treatment recommendations are impeded by difficulties with health insurance. And I am sure my patients are not alone in suffering the consequences:
Ms. D, came in Wednesday. She has high blood pressure and very high cholesterol. I had not seen her in over six months, but she works a demanding job, so I figured that she had just been busy. In the office, we did not talk about her blood pressure. We did not talk about diet and exercise. She had not followed up for so long because at the prior visit I had sent her for an echocardiogram of the heart and she was billed $800 for the test. Her insurance would only cover $200. We spent the entire visit talking about how she could not afford to pay this bill. I just don’t get it. She has private health insurance. She was having symptoms that had been worsening over several visits and needed further evaluation – exercise intolerance and palpitations. Now, she is receiving daily letters from a collections agency, and she is frightened to come to the doctor because of the bills that may show up in the mail.
Mr. D, a security guard with diabetes, hurt his knee while fishing and had severe pain and swelling. When I initially saw him a few weeks ago, there did not seem to be any major structural damage to the ligaments, so I recommended a conservative approach with rest, ice, and anti-inflammatory medications. Now, several weeks later, the pain and swelling had not subsided, so I ordered an MRI to evaluate for more subtle damage to the knee. After several attempts at prior authorization, the private insurance company refused to pay for the test. Baseball players get MRIs the same day for any bump or bruise, but even going through the appropriate prior authorization process, I could not order an MRI for my patient with private health insurance. I am not looking forward to all the phone calls that it will require to protest this denial of necessary diagnostic test.
On Thursday, Mr. F came in to have his blood checked. He requires blood thinners to prevent recurrence of blood clots which could be fatal. He has twice previously had clots in the blood vessels of his calves, and he once had a blood clot travel to his lungs. He has a clotting disorder that makes any break in treatment with the blood thinners extremely dangerous. Warfarin is an effective and inexpensive blood thinner, but it requires frequent monitoring because its activity is affected by numerous interactions with other medications and foods. His blood test showed that the warfarin was not doing its job, so I recommended an increased dose. It takes about three days for the dosage change to have a full effect, so I also recommended injectable blood thinners, which act more rapidly, until we could demonstrate that his warfarin had reached a therapeutic level. However, he could not afford the copay for the injectable blood thinner, so he must hope that he does not develop another blood clot as we wait for the higher dosage of warfarin to take effect.
Yesterday, I saw Ms. E for a follow up appointment. She is only in her 30s but has already had major back surgery for a disk problem. She stands for six hours a day at work and has recently had worsening of her back pain. Her spine specialist had recommended physical therapy, instead of a repeat operation, but she cannot go because her private insurance company requires a copay for every session. She has been unable to work because of the worsening pain, so she cannot afford these copays and has not been able to follow the treatment plan. I do not want her to become dependent on pain killers, but since the treatment recommended by her orthopedist is not a realistic possibility, we are running out of options.
I could fill many pages with stories like these of my patients whom are hard working, have private health insurance through an employer, but just cannot get the care that they need, because of unreliable coverage. It frustrates me that executives of health insurance companies spend millions on advertising to disparage public health insurance, and Republican politicians are stone walling meaningful health care reform because they are afraid that a public health insurance option would put private health insurance companies out of business. I do not care who provides health insurance for my patients. Whether they have public or private insurance, I just want them to get the best care possible. If private health insurance companies provide a high quality product, they will not be “forced” out of business by a public plan. It makes sense that competition between a public plan and private plans would lower costs, improve quality, and guarantee an option to those who do not have employer sponsored coverage. As a physician, I need to advocate for my patients. Private health insurance companies have thousand of lobbyists and millions of dollars to spend. So why do these companies need so many politicians, including Democrats, advocating for them as well? This is not about ideology. It’s about patients who cannot afford their medications or who face bankruptcy due to medical bills. We need meaningful change and we need it now.
- Aaron Fox, MD
1 Comment April 14th, 2009 by Aaron
April 13, 2009
Today at the Interchurch Center in Morningside Heights, Senator Kirsten Gillibrand (D-NY) met with a diverse group of community activists, labor leaders, and health care professionals to discuss priorities for health care reform. The demands of the group were simple – quality affordable health care we all can count on – and Senator Gillibrand’s response, which included overwhelming support for inclusion of a public health insurance option in any legislation on health care reform, suggested that she will be a strong advocate for health care reform in the near future.
The round table discussion was organized by Health Care for America Now! (HCAN), a coalition of 850 member organizations committed to common principles for health care reform. In attendance were representatives from 1199 SEIU, AFL-CIO, ACORN, Citizen Action of New York, the New York Immigration Coalition, NYC for Change and about 20 other local and national organizations. In addition to Senator Gillibrand, NYC Councilman Daniel O’Donnell and a staff member from Congressman Ed Towns’s office were also in attendance. As a practicing physician, and a representative of the National Physicians Alliance, it was heartening for me to see so many people committed to fixing our broken health care system.
The meeting began with a welcome from Paula Mayo, Director of the Interchurch Center, and introductory remarks by Dr. L. Toni Lewis, president of the Committee of Interns and Residents. Dr. Lewis shared an example of the tenuous nature of health care delivery in our communities – the hospitals in which she trained, Mary Immaculate and St. John’s, have both recently closed leaving patients in an already underserved area of Queens in flux. She also introduced HCAN’s policy priorities: enacting legislation in 2009 that would guarantee the option of a public health insurance plan and working toward equal access to quality care in communities of color and low income areas.
The most compelling speaker at the round table, a young woman named Kelly Cuvar, shared an extremely personal story of her battles with both cancer and her private health insurance company. Diagnosed with cancer at 19, she described how every major life decision she has made since has been framed by the need to maintain health insurance coverage. Never in full remission despite treatment, her “prior condition” and her ongoing need for doctor visits and treatment has made every interaction with the insurance company a source of stress. “Everything was fight,” but at least as a 19 year old student, her father could do the battling with the insurance company. Now 10 years later, after losing her job last year and needing to pay for her coverage through COBRA, she is petrified that her coverage will run out, “I am frightened and it is all that I think about.” In arguing for an affordable public health insurance plan without restrictions on prior conditions, she made the heart breaking plea that she is hard working, she has bravely battled her cancer, but our convoluted system of health care is failing her and has left her uncertain about her future care.
Other speakers included Sherriann Cumberbatch, a small business owner from Staten Island who cannot afford health insurance for her employees or even her own family; Elisabeth Benjamin of the Community Service Society who questioned why private health insurance premiums in New York have been increasing at 81% – a rate seven times greater than increases in wages; Ralph Palladino of AFSCME DC 37 who argued that a public health insurance plan would introduce competition, stability, efficiency, and innovation into markets where the private insurance industry has failed to do so; and Theo Oshiro of Make the Road New York who emphasized that immigrant families pay taxes and contribute to the economy and should not be barred from public health insurance plans.
In response, Senator Gillibrand only spoke for a few minutes, but immediately affirmed her support for including a public health insurance plan in any health care legislation. She also acknowledged support for a House budget resolution that would allow the Senate to pass health care reform with a simple majority vote avoiding filibuster. She was clearly moved by Ms. Culver’s comments and spoke directly to the young woman telling her that the stress and strain that her family went through is unacceptable. In a flurry of powerful statements, Senator Gillibrand emphasized that a not for profit public plan must be affordable (no more than 5% of a family’s income and less for those who can afford less), easy to enroll in (suggesting a check box on tax forms for enrollment), allowed to negotiate for discount prices with pharmaceutical companies (similar to the VA), and should offer coverage to everyone. To her, health care is right, not a privilege. The junior Senator from New York is clearly going to be a champion for progressive health care reform…now what can we expect from Mr. Schumer…
Aaron Fox, MD
Add a comment February 9th, 2009 by bronxdoc
As Valentine’s Day approaches consumers are importuned to purchase flowers and various other tokens of love. Our colleague Martin Donohoe, editor of the Public Health and Social Justice website passed on to us some materials looking impact of flowers, diamonds and gold on workers’ health and the environment. His concerns challenge us to think of less harmful, less exploitative ways of showing affection (see below).
Dr. Donohoe’s arguments were presented in a 2008 article published in the Health and Human Rights Quarterly entitled: Flowers, Diamonds, and Gold: The Destructive Public Health, Human Rights, and Environmental Consequences of Symbols of Love. Here we will briefly summarize his arguements.
Flowers:
About 190,000 people in the developing world are employed in the global floriculture industry. Most of the workers are women with low paying, no benefit jobs. “Child labor, dismissal from employment due to pregnancy, and long hours of unpaid overtime are common, especially before holidays such as St. Valentine’s Day and Mother’s Day.”
Floriculture is also the largest consumer of pesticides, one fifth of which are either untested or banned in the US. Workers in greenhouses may be exposed to particularly high levels of pesticides. Proper conditions for the handling and removal of pesticides may not exist. All of this has health consequences for the workers. [For a powerpoint version of this information see Dr. Donohoe’s presentation Floriculture Industry: Thorns without Borders.
Diamonds
The exploitation of diamond workers has long been well documented, see for example the report by Global Witness on poverty diamonds in Africa. What has become clearer in the past few years is the role of so-called conflict diamonds in fueling political turmoil in Africa as well as financing Al Qaeda.
Gold
Like diamonds, gold miners work in “the world’s most deadly industry.” Ironically, gold mining areas often show slower rates of sustainable economic development. Gold mining has tremendous ecological consequences. A single 18 karat gold ring is estimated to produce eighteen tons of waste.
For a general overview of the impact of mining on communities, see Oxfam’s report Dirty Metals: Mining, Communities, and the Environment.
Dr. Donohoe’s article ends with suggestions (which we have supplemented) for alternative non-exploitative, non-harmful ways of expressing love:
Flowers: Various unsuccesful attempts have been made to create eco-labels for flowers. One that is still in existence is Veriflora. In 2008 the Organic Consumers Association offered suggestions for where consumers could obtain organic flowers. Of course, the best alternative to cut flowers is to grow them yourself. For those of us who live in cities we are fortunate that there are now many urban gardens. Our colleague Julianna Mantay at Lehman has actually mapped community gardens in the Bronx (see Urban Agriculture/Urban Oases in the “Concrete Jungle”: The Culture of Community Gardening in the Bronx). Unfortunately, community gardens are not the solution to flowers in February in New York City. But they can be grown indoors.
Gold and Diamonds: The No Dirty Gold Campaign asks consumers to sign a pledge asking for reforms in the gold mining industry.
The article concludes:
Consumers should reconsider the entire concept of purchasing cut flowers, gold and diamonds as symbols of their affection. These symbols are not
universal and have not been constant throughout history, but rather are cultural constructs extensively perpetuated by the persuasive marketing efforts of multinational corporations. The visible reminders of one’s love should not also represent environmental destruction, violence, the subjugation of native peoples, child labor, and human rights abuses.
Substitute gifts include cards (ideally printed on recycled paper), poems, photos, collages, videos, art, home improvement projects, homemade meals, and donations to charities. Consider alternatives to the traditional diamond engagement and gold wedding rings, such as recycled or vintage gold: old gold can be melted down and made into new jewelry. Other options include eco-jewelry made from recycled or homemade glass and coconut beads. Purchasing handicrafts constructed by indigenous peoples from outlets that return the profits to the artisans and their communities provides wide-ranging social and economic benefits. Such tokens of affection will be rendered more meaningful through their lack of association with death and destruction and because they symbolize justice and hope for the future.
Taking up Dr. D’s suggestion of giving poetry for Valentine Days, here is a love poem from the Roman poet Catullus. It suggests yet another way of showing love.
Let us live, my Lesbia, and let us love,
and let us judge all the rumors of the old men
to be worth just one penny!
The suns are able to fall and rise:
When that brief light has fallen for us,
we must sleep a never ending night.
Give me a thousand kisses, then another hundred,
then another thousand, then a second hundred,
then yet another thousand more, then another hundred.
Then, when we have made many thousands,
we will mix them all up so that we don’t know,
and so that no one can be jealous of us when he finds out
how many kisses we have shared.
posted by Matt Anderson, MD
