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Opinion and Commentary from TMA

The Financial Burden of Cancer Care

(Public Health) Permanent link

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 This post originally appeared on the Angelina Radiation Oncology Associates website

As a board-certified radiation oncologist, I’m trained to know all about cancer and its physical effects on people. Similarly, as a board-certified hospice and palliative care physician, I am well-versed about the psychosocial and spiritual trials patients go through, especially at the end of life. But a recent study I read stopped me in my tracks with a disturbing finding: Cancer is bankrupting an astounding number of patients. 

Sid_RobertsAdrienne Gilligan, PhD, publishing her research in the American Journal of Medicine, found that 42 percent of cancer patients deplete their life savings within two years of diagnosis. This “financial toxicity” — arguably every bit as serious as the emotional and physical toxicity associated with cancer treatment — risks forcing far too many cancer patients to make an agonizing choice between almost certain death and overwhelming debt.

The Advisory Board Company, a Washington, D.C.-based organization that researches best practices in health care and other industries, highlighted from Gilligan’s article that “the direct medical costs from cancer exceed $80 billion in the United States. [The authors] cited previous research finding that up to 85 percent of cancer patients leave the workforce during their initial treatment, and more than 50 percent of cancer patients at some point experience bankruptcy, house repossession, loss of independence, and breakdowns in their relationships.”

One observation from this research that should be even more concerning for those of us in deep East Texas, is that in more vulnerable populations with lower socioeconomic status and clinical factors such as smoking and poorer health — this describes Angelina County and surrounding counties — the risk of asset depletion is even greater. Even for those with health insurance, the researchers wrote, deductibles and copayments for treatment, supportive care, and nonmedical or indirect costs (for example, travel, caregiver time, and lost productivity) may be financially devastating.

I see this financial burden all the time. Monthly, I get a report from my billing office on the bills that patients are not paying despite multiple contacts. Most of the time, these are deductibles and copays that patients — who live paycheck to paycheck and who have no savings to start with — never are going to be able to pay. Sometimes it is the entire bill, in the case of uninsured and indigent patients. As a physician, I really only have two options: send them to a collection agency to harass them and try to get whatever proverbial blood out of the turnip they can, or write them off. That my patients should suffer not only with a cancer diagnosis and treatment side effects but also possible bankruptcy is absurd. I am rightfully appalled and angered that our federal health care reimbursement system and the private insurance complex have achieved “cost savings” by placing more and more of the financial burden onto patients, who simply are unable to pay. The bankruptcy monster is always at the door.

Doctors are familiar with the Latin phrase primum non nocere — first, do no harm. The idea is really that we should balance the risks of treatment with the benefits. I imagine when that phrase was coined the author did not have financial harm in mind. Today, it has become one of the most important “risks” when weighed against the hoped-for gains of treatment. Unfortunately, the provision of health care has become a commodity, and providers are reduced to revenue-producing cogs on the wheel in a system that has replaced the patients’ needs with productivity metrics. The profession of medicine is less and less in charge of the provision of medicine.

In spite of this new reality, health care providers — doctors, hospitals, etc. — must recognize that the mission of any health care organization is first and foremost health, not profit. When profit alone drives health care decisions, the cart is before the horse. And forcing patients into bankruptcy with draconian billing and collection policies profits no one (except maybe collection agencies). Accounts that have little chance of being paid need to be written off quickly and completely.

In hospital systems, some critical services — for example, social work, patient navigation, discharge planning — may have no direct link to the bottom line in terms of a reimbursable, codable procedure or office visit, but nonetheless have a profound impact on preventing financial losses by impacting readmission rates and avoidable costs associated with inability to comply with prescribed courses of treatment. In addition, finding sources of payment for patients can bring dollars in that otherwise would not be seen. These services must not only continue, but be expanded.

Ultimately, legislators need to change the way health care services are valued and reimbursed so that the increasingly unmanageable financial burden that falls on everyone — even the insured, hardworking folk — doesn’t bankrupt us all. This isn’t about patient responsibility; it is about preventing personal financial catastrophe. And now it’s January with high deductibles and never-ending copays to meet. I’m afraid we are in for a bumpy ride.

Happy New Year!

Sidney Roberts, MD, is a radiation oncologist in Lufkin

A Dozen Ways the Shutdown is Affecting Health Care

(Legislature, Public Health, U.S. Congress) Permanent link

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This is an exceprt of a post originally published on Sarah Fontenot’s website.  

As other industries are struggling through the partial government shutdown, it would be easy to feel positive about health care. Funding for both Health and Human Services (HHS) and the Department of Veteran Affairs (VA) are secure due to appropriation bills that predate the current crisis. VA benefits, Medicare, Medicaid and the Affordable Care Act (also known as Obamacare) are — at least at face value — protected. 

The Centers for Disease Control and Prevention (CDC) is up and running, the National Institutes of Health (NIH) continues to oversee biomedical research, and Food and Drug Administration (FDA) responsibility for drug approval is not affected.

But that is not the whole story.

The shutdown is impacting — even risking — the health of countless Americans. Protections and processes all of us rely on are on hold. Innovations and developments in science, policy, and the law are being delayed or subverted.

Starting with the most important examples — people who are directly affected — here are 12 ways this shutdown is doing damage in the realm of health care.

1. Some Federal Workers are Losing Their Health Benefits  

The 800,000 employees at shut down federal agencies who fall under the Federal Employees Health Benefits (FEHB) program are not at risk of losing their health care insurance. But they could start to receive bills for their dental, vision, and long-term care coverage if the crisis continues. 

The federal employees most in jeopardy are those working under contracts not eligible for the FEHB program. Not only are contract workers potentially not going to get paid when the shutdown ends, they lost their health care benefits at midnight on Dec. 22. A poignant story highlighted by NBC News and the New York Post covers a young woman from the Interior Department now rationing her insulin because she cannot afford the cost.

2. Many Native Americans are Going Without Health Services  

The Indian Health Service — run by HHS but funded through the Department of the Interior — is directly affected by the shutdown. Native American tribes have already missed millions of dollars in essential services; only health care that meets the "immediate needs of the patients, medical staff, and medical facilities" are included in the department’s shutdown plan. Some clinics serving Native Americans have closed already; others are expected to cease services by the end of this week. 

3. Some People Eligible for ACA Subsidies May Have Their Applications Delayed  

Many (if not most) people who purchase insurance on the Affordable Care Act (ACA) Exchanges (or “Marketplaces”) receive a subsidy from the government to help them afford health care coverage. Applications for subsidies may require an Internal Revenue Service (IRS) review in some circumstances, such as when applicants lose their job, a baby has been born, or the person involved filed for an extension on paying income taxes or signed up for insurance outside of the open enrollment window.

With 90 percent of IRS workers out of the office, these applications are now delayed — and the patients involved could lose their insurance entirely if they can’t pay the full premium while they are waiting. (As a bonus, the IRS Call Center is closed so these people can’t get information on what they should do.). Democratic senators andrepresentatives sent a letter Monday to HHS and Treasury asking for protection from unexpected premium costs due to the shutdown.

4. People Who Receive SNAP Benefits (Food Stamps) Have Another Month of Coverage  

The United States Department of Agriculture, Food and Nutrition Service (FNS) released funds to each state to provide February Supplemental Nutrition Assistance Program (SNAP) benefits two days before the shutdown. This means people who receive SNAP (food stamps) must ration their benefits to last two months; it is unclear if there will be any further assistance if the shutdown continues into March.

People who were in the process of applying for food stamps when the shutdown began may have to go without until the reopening of the government. Although the SNAP program is administered through the states, “FNS does not guarantee eligible applicants will receive food stamp benefits while the partial federal shutdown is in effect,” St. Louis Public Radio wrote.

5. Food Safety Issues May Affect Public Health  

Food safety is a basic component of public health, and it is now threatened by the interruption of routine food safety inspections. However, the day after FDA Commissioner Scott Gottlieb confirmed the cessation of food control efforts, the FDA announced that “high-risk” inspections, including infant formula, shellfish, and prepared salads and sandwiches, will resume with the return of 150 furloughed (but still unpaid) people next week.

6. Industry Developments Are Affected by Government Regulators’ Lack of Funding  

The Antitrust Division of the Justice Department asked the U.S. District Court in Washington, D.C., last week to suspend review of the $70 billion CVS-Aetna merger due to lack of resources. The judge told them to keep working.

This “mega-merger” is a highly publicized case — and the judge’s opinion presumably reflects that. Undoubtedly there are lesser-known business dealings and corporate plans that cannot come to fruition while the necessary federal agencies are unavailable to serve their role.

7. The Safety of Drinking Water is Threatened  

After what is happening in Flint, Mich., water safety is top-of-mind for all health care providers, but with more than 13,000 workers furloughed, the Environmental Protection Agency does not have enough staffing to inspect drinking water adequately.

8. State 1332 Waivers for Innovations in Marketplaces are on Hold  

IRS evaluation of the financial impact of proposed innovations is a central component in a state’s process to obtain a 1332 waiver, but because the IRS is currently crippled (see above) that agency can’t work with HHS to evaluate state initiatives to revamp their ACA marketplaces, a chief focus of conservative efforts to alter the ACA.

9. The Appeal of the Texas Decision Striking Down the ACA is on Pause  

The federal court system has survived the shutdown by conserving resources as best as possible (although a closure could happen as early as next week), but the shutdown has still impacted the most prominent court case in health care today: the Texas lawsuit decided in December declaring the entire ACA invalid. On Jan. 11, the 5th Circuit Court of Appeals in New Orleans issued a stay in the appeal of that decision until the government reopens.

10. The FDA is Open — but New Drug Treatments may be Delayed  

The FDA, as a branch of HHS, is up and running, but even so, some pending new drug treatments (including those for multiple sclerosis, depression, and diabetes) may be delayed if the shutdown continues, as the agency cannot process the application fees paid by drug manufacturers during the shutdown. Funds available at FDA are expected to be exhausted before March. 

11. It is Increasingly Difficult to Hire Researchers at the FDA  

In 2016, the passage of the 21st Century Cures Law (Pub. L. 114-255) was “designed to help accelerate medical product development and bring innovations and advances to patients who need them faster and more efficiently.” Part of that directive was to accelerate hiring scientists (and increase their pay) at the FDA. However, as recently reported by Bloomberg, the shutdown is making it difficult to entice the best minds away from the private market — to reinforce the argument that the government is “a good place to work.”

 

12. Activities of Homeland Security Related to Health are at Peril  

The division of the Department of Homeland Security that monitors threats related to infectious diseases, pandemics, and biological and chemical attacks (the Office of Health Affairs) is scaled back throughout the shutdown. Of the 204 people who typically address these threats as well as others in the Countering Weapons of Mass Destruction Office, only 65 remain active.

Other Homeland Security employees who will continue to work without pay include border health inspectors and members of the border patrol.

This shutdown is a world of pain for all of us. But for many, it is an actual threat to life (such as living without insulin).

2019 will be a year of political battles over the future of the American health care system on both a federal and state level. The Trump Administration will (presumably) continue to erode protections provided in the ACA, and the December case ruling the entire ACA unconstitutional will continue to wind its way toward a newly constituted conservative U.S. Supreme Court. The ying and yang of “Medicare for All” and “Free Market Health Care” will be the debate of the year. All of that, and much more, will be the subject of future Fontenotes.

But until our government fully reopens — those debates all seem irrelevant — if not irreverent.

 

Rural FP Finds Rewards With Full-scope Training, Deep Roots

 Permanent link

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This story was originally published in AAFP News.

With 268,581 square miles of ground, Texas is second among all states in the nation when it comes to total land size. It's also home to nearly 28.5 million people — 3 million of whom live in rural communities. 

Shelley Kohlleppel, MD, a native Texan, is doing her part to give back by providing health care to about 6,000 patients in her solo family medicine clinic in Lakehills, Texas.

Dr. Kohlleppel's road to family medicine is a classic tale of a girl born and raised in a small rural town who entered medical school and then residency with every intention of staying close to her hometown roots.

"I shadowed a physician before I got into medical school," Dr. Kohlleppel told AAFP News. "That's where I discovered I wanted to be a family physician." 

After graduating from the McGovern Medical School at the University of Texas Health Science Center at Houston, and completing the John Peter Smith Hospital Family Medicine Residency in Fort Worth, Dr. Kohlleppel stayed in her home state. 

"I was able to get $160,000 (paid out over four years) from the state of Texas for my loans because I wanted to practice in a rural area," she said. 

This is the story of her journey. 

Finding her way

Even though Dr. Kohlleppel grew up in a farming community near LaCoste, Texas, just 45 minutes away from her current practice, it still took some time to find her footing in Lakehills. Nearly seven years, to be precise.

Straight out of residency, she tried working for a large group practice in San Antonio, but she knew it wasn't a good fit after just one year. Soon after, Dr. Kohlleppel bought the then-shuttered satellite Medina Lake Clinic from her employer and launched her solo practice.

She wheedled her way into the hearts of the locals by immersing herself in the community. For starters, she showed up at the town fire department, attended public meetings and began volunteering at various functions.

Next stop, places of worship. "We have lots of churches, so I just started going to all their fundraisers — getting to know each church and its attendees — and before long, everyone in the community knew me," said Kohlleppel.

From there, her practice took off. Dr. Kohlleppel is the only family physician in town; in fact, there's not another physician of any specialty for at least 30 miles in any direction.

There is one downside to all that comradery. "A lot of people like to call me Shelley instead of Dr. K or Dr. Kohlleppel, and that's been kind of hard. But I do understand, because for many people here, I've become part of the family," she said.

Relishing time with patients

Dr. Kohlleppel quickly settled into a clinical practice routine that mirrors those of family physicians across the country — except her patient panel exceeds Lakehills' total population by nearly 1,000.

She employs a staff of three: two front-office personnel and a recently hired nurse practitioner.

The phrase emblazoned across her practice website — "Modern Medicine with Old Fashioned Kindness" — epitomizes the compassionate health care Dr. Kohlleppel strives to provide her patients, including the occasional house call when necessary.

"We were trying to get a patient set up on hospice care, and the Blue Cross HMO was giving us some craziness about all the approvals they needed to make that happen. So I went ahead and visited him in his home to try and get him settled until we could get hospice on board," said Dr. Kohlleppel.

This family physician is tuned into her town and those who live there, and she's acutely aware of patients who struggle economically. And so on occasion, when a person comes up short on the payment end, Dr. Kohlleppel isn't opposed to getting creative.

The new shingles on her office roof serve as an apt example of her willingness to barter, a learned kindness she attributes to her farmer father.

Dr. Kohlleppel's full-scope training comes in handy in a town with no other physician. "I do any procedure I can do in clinic — like toenail removal, lesion removal, fractures, sutures," along with the necessary chronic, preventive, and wellness care for all ages, she said.

Above all else, Dr. Kohlleppel relishes listening and learning.

"Based on what my patients tell me, I like to talk," said Dr. Kohlleppel with a laugh. "That's been my passion from the start. I like to sit down and chat with them — go through things. Patients tell me their doctors in San Antonio and in bigger practices don't spend that time with them and stick to the 15-minute visit."

Early on, Dr. Kohlleppel tried to branch out. She experimented with providing care to nursing home patients in neighboring Bandera, but after a year of traveling back and forth, she realized the clinic suffered in her absence.

With some reluctance, she also passed on including obstetrical care in her menu of services, something she very much enjoyed during residency. Kohlleppel understood that taking on 24-hour call to deliver babies — when the nearest hospital is 45 minutes away — wasn't realistic for a solo family physician.

Making it work

Opening and maintaining a solo practice is not for the faint of heart, and Dr. Kohlleppel isn't shy about pointing out the challenges.

The lack of professional support weighs heavily on her. "I have not taken a vacation in seven years, and sometimes, when I have to be out of the office, I feel guilty. What if a patient needs something when I'm gone?"

And being just 40 miles from San Antonio is a disadvantage in that some patients cling to their "city" physicians for primary care and rely on Dr. Kohlleppel for urgent care, especially when it comes to pediatric visits.

"I constantly educate families and remind them I am a primary care doctor and can take care of everything for them," she said.

Staff turnover is another prickly topic.

"It's hard to pull from the workforce pool out here. We're about 30 minutes from the outskirts of San Antonio, but a lot of people don't want that daily drive to work," said Dr. Kohlleppel.

Furthermore, people living in Lakehills or any of the surrounding towns that pepper the Texas countryside — including Pipe Creek, Bandera, and Mico -- can command a larger paycheck in the city.

Dr. Kohlleppel noted that in the not-so-distant past, meeting payroll and overhead sometimes meant she held her own paycheck, a scenario no small business owner ever wants to face.

However, a recent positive change involved switching from in-house billing to an outside billing company with a certified coder on staff. Dr. Kohlleppel is now far more confident that she's pulling in the appropriate payment for services delivered.

Crystal ball gazing

Dr. Kohlleppel acknowledged the hard work it takes to build a solo practice but declared she's in it for the long haul. "I'm here until the Lord says it's time to go, so I'm going to make sure that my practice is stable," she said.

"Once I get my main building paid off, I plan on expanding the clinic and making it easier for my patients and myself."

Her wish list includes growing the practice to include another family physician, physical therapy options for patients, and a pharmacy.

In fact, there's no pharmacy in town, and the only delivery option is one pharmacy in Bandera that delivers to patients only one day a week.

"When patients see me, they literally have to drive 30 minutes to the pharmacy and 30 minutes back," said Dr. Kohlleppel.

Optimally, someday she'll have available space in her building for a small pharmacy to operate, even if it's for just a few hours a day.

"It would be nice if patients could leave with some antibiotics," she said.

"I grew up as the second of nine kids," said Dr. Kohlleppel. "My parents taught me about helping out in the community, giving back to the community, and using what you can within the community.

"Sometimes you just have to do what it takes to help people out," she said.

Reprinted with permission of the American Academy of Family Physicians