(dis)covering the Uninsured and (ad)dressing Needs by looking no further than one's own closet

(dis)covering the Uninsured and (ad)dressing Needs by looking no further than one's own closet Dennis F. Saver, M.D. FSU Medical Grand Rounds March 24, 2011

I. Professionalism and Ethics

AMA Principles of Medical Ethics Preamble The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.

AMA Principles of Medical Ethics VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. IX. A physician shall support access to medical care for all people. Adopted June 1957; revised June 1980; revised June 2001

Asklepios (before Hippocrates) The Asklepian tradition in the age of the divine Asklepios is clear in its commitment to equal service to all people, and it demands this commitment of its physician followers. An inscription at the Athenian temple to Asklepios on the Acropolis reads These are the duties of a physician he would be like God savior equally of slaves, of paupers, of rich men, of princes, and to all a brother, such help he would give Oliver JH, Maas PL. An ancient poem on the duties of a physician. Part I and II. Bull History Med. 1939:315 23.; cited in: Asklepios: Ancient Hero of Medical Caring, James E. Bailey, MD, MPH; http://www.annals.org/content/124/2/257.full?sid=539776c8 72e5 4639

Medical Ethics As a physician, do you have a duty to the community of mankind in which you live? Is there a moral responsibility to the less fortunate, which balances the rights and privileges you are granted as a physician? Ethics simplified: Have a heart

II. Case Study: One Doc's Journey

II. Case study: One Doc's Journey Medical College of Pennsylvania NHSC Scholarship years 3,4 Family Medicine Residency University of Florida NHSC assignment to Rural Health Initiative, Newburg, WV 8 more years private practice in Newburg Move to Vero Beach, FL

II. Case study: One Doc's Journey Starting We Care in Indian River County Request by HD for subspecialty access for indigent and Medicaid patients, 1991 Committee of ~8 physicians volunteered Signing up all physicians in a subspecialty for work in rotation. [Many hands make light work.] HD nurse did coordination activities, by having other staff pick up her usual work. NOT SUSTAINABLE.

II. Case study: One Doc's Journey Starting We Care in Indian River County IR County Medical Society applies to Hospital Tax District to fund a nurse coordinator position; hired and housed at HD Volunteers increase from 67 in 1992 87 140+, now average ~130/yr

Number of Volunteers Indian River County "We Care" Program 160 140 120 100 80 60 40 IRCMS leaves program Number of Volunteers 20 0

II. Case study: One Doc's Journey How We Care works patient registers and qualifies as county resident and meeting <200% federal poverty level paid nurse coordinator volunteer physicians and HD physicians do primary care evaluation and create data base, obtain labs/studies refer for subspecialty care as indicated indigent drug program (IDP) application

II. Case study: One Doc's Journey What I do clinic every other Monday (AM 3 4 hrs) chair the committee solve problems, grease the wheels special projects (GI clinic, Surgery Clinic) recruitment, recruitment, recruitment

II. Case study: One Doc's Journey Starting We Care in Indian River County Value of donated services $200K >$1 M per year Indigent Drug Program applications for patients starts being a formal and tracked activity, now >$800K /yr

Dollar Value of Services Provided Indian River County "We Care" Program $1,200,000 $1,000,000 HD hires IDP clerk $800,000 Donated Services $600,000 IDP Medications $400,000 $200,000 $0 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

II. Case study: One Doc's Journey Starting We Care in Indian River County Number of completed referrals 200 max 3500; currently around 2500/yr Featured in Wall Street Journal section front page article 1999

Completed Patient Referrals Indian River County "We Care" Program 4,500 4,000 3,500 3,000 2,500 Completed Patient Referrals 2,000 1,500 1,000 500 GYN moves out independently 0

II. Case study: One Doc's Journey Starting We Care in Indian River County This DOES NOT solve the problem of medical care access for indigent patients in Indian River County. Not in the past, not now, and not in the future. But it is a help.

III. What are the rewards for providing volunteer service?

Rewards for Volunteer Service In Vero Beach: Box of cookies on Valentine s Day Newspaper Thank You 1/year

Rewards for Volunteer Service In Vero Beach: Box of cookies on Valentine s Day Newspaper Thank You 1/year A good experience of "just being a doc The difference between a gift and a tax - how virtuous do you feel? Fulfillment of professional ethic

IV. "We Care" as part of the FMA and the DOH

What people do locally depends on resources We Care in Tallahassee Volunteers in Medicine in Stuart Polk County program Hillsborough County - half cent sales tax

The half-cent county sales tax generated $92 million in revenue this year [2010], of which $14 million was the local match for the state's Medicaid bill.

We Care in Polk County We Care is a not-for-profit program in Polk County that assists people with serious medical problems with volunteer medical specialists and clinics in the county. The program was started by the Polk County Medical Association and has been in existence since 1999.. The program is state and county funded and while that helps the program connect patients with healthcare specialists, the funds do not cover other related medical costs. "We depend heavily on donations from the community to help get patients their medications, to get different kinds of diagnostic testing that they need and without those donations, we really wouldn't be able to any more that get the patients to see a doctor," said Sandy Swanson, executive director of the We Care of Polk County... Services are limited to conditions which are significantly medically necessary/life altering and cannot be treated or managed by the primary care provider. We Care staff works diligently to ensure the patient is able to follow the provider's recommended treatment plan at no or little cost to the patient. http://www.wtsp.com/news/local/story.aspx?storyid=166953, accessed 2011-03-05

State of Florida Volunteer Health Services http://www.doh.state.fl.us/tobac co/vhs/archive/volunteer/annu al_reports.html

V. Community Health Centers The Good dedicated to the underserved Federal grant; providers not at risk Networks; now integrating into medical student training

V. Community Health Centers The Not So Good No effective oversight Newburg, WV story Politics and local issues

VI. Some patient stories Pat evicted and no teeth Nick with MS; "Make the best of it that I can" Donald, small cell Ca and still smoking Jackie melanoma, depression George demanding more GI consultations

VII.Challenges in treating the uninsured

VII. Challenges in treating the uninsured 1. Are their resources to treat a problem found? If there are not, how useful is it to screen? Clinical practices that screen for depression should have systems in place to ensure that positive screening results are followed by accurate diagnosis, effective treatment, and careful followup. Benefits from screening are unlikely to be realized unless such systems are functioning well. USPSTF 2002 http://www.uspreventiveservicestaskforce.org/3rduspstf/d epression/depressrr.pdf

VII. Challenges in treating the uninsured 2. What is routine, urgent, and emergent? 3. Who can you call to help? 4. Those who won't contribute to help themselves 5. Those who abuse the system 6. Can the effort be sustained?

VII.What can one person do?

VII.What can one person do? Look for opportunities

VII.What can one person do? Look for opportunities You don't have to be Mother Teresa to do good works

VII.What can one person do? Look for opportunities You don't have to be Mother Teresa to do good works Look for colleagues to join you

VII.What can one person do? Look for opportunities You don't have to be Mother Teresa to do good works Look for colleagues to join you Decide how much of a financial commitment you can make

VII.What can one person do? Look for opportunities You don't have to be Mother Teresa to do good works Look for colleagues to join you Decide how much of a financial commitment you can make Put yourself in the shoes of those who have none; the uncovered could well be your family

VII.What can one person do? Look for opportunities You don't have to be Mother Teresa to do good works Look for colleagues to join you Decide how much of a financial commitment you can make Put yourself in the shoes of those who have none; the uncovered could well be your family Be stubborn; don't take "no for an answer

VII.What can one person do? A LOT!!!!

VII.What can one person do? You can dis cover the underserved if you care to look

VII.What can one person do? You can cover the underserved with the skills you have ( in your closet )

Thank you for listening, and for what you will do in the future! Questions?????