Monday, September 9, 2013

It's all about the Benjamins, baby.

This is Kristi. She's one of the amazing hospital pharmacists at Grady Hospital. She is smart and diligent and empathic and generous with her knowledge. I stopped in her office today along with one of the residents because I needed her help.

The question wasn't about the pharmacokinetics of some drug or even about some kind of drug-drug interaction. Nope. This was question about what is, unfortunately, one of the most common things that gets discussed at public hospitals: Cost.

Okay, so check it. Grady Hospital and the handful of other safety net hospitals in the U.S. that turn no one away due to limited ability to pay has programs in place specifically for our poorest patients. That is, if you are at 200% of the U.S. poverty line or below, you qualify for a significant amount of assistance with whatever it is you need. And that? Now that is wonderful thing.

Now. If you are like me, you probably have no idea what 200% of the federal poverty level is. And maybe you are one of those people who just walks around with that kind of information in your head, but I'm not. So me? I had to look it up today. And I'll tell you why.

I saw a patient today who was sitting in front of me in a work uniform. Had worked some crazy oddball shift in order to get out in time to make this appointment with us for management of high blood pressure and diabetes. And really, this patient was super motivated, kept appointments, and went through great effort to make it over to see us.

Okay, so we check the lab results from the most recent blood draw and things look horrible. Like for real, horrible. The blood sugars are out of whack and the patient is clearly not doing what we asked at the last visit. And so we asked the patient straight up:

"What's up with your blood sugars? Is everything okay?"

"No," our patient replied, "I only take my insulin here and there because I can't afford it. I can't afford the blood pressure pills, neither."

And that was weird because this patient wasn't new to us. I mean, this patient had been coming to Grady in that same work uniform for many years. Why was this suddenly an issue?

My resident blurted out a question before I could. "Don't you have a Grady card?"

What she was speaking about was the sliding scale card given to patients with limited ability to pay. The patient gave a hard head shake.

"I used to. But my job gave me just a little bit more money so now I don't qualify no more."

And let me tell you. This patient was a hard worker. I also know that uniform was not one worn by a person who makes stacks and stacks of money. And so we talked about it and the patient said, "Essentially, I am now just over the line." Which was later clarified to be 201% of the federal poverty level. I agreed to look into what we could do to assist by talking to Kristi and also our social worker.

And so. I also looked to see what that all meant in concrete language.

 Household Size
 For each additional person, add

It gets cut off on this chart, but just know that $22,980 was the 200% marker for a single person and $31,020 for a two person household. Yeah. So my (single) patient was making like $24K per year up from like $22,500. And you know what? That patient was working hard for that little bit of money. Hard.

And so. I talked to all of the people that you talk to about these kinds of things and heard the same answers. Which essentially is that in order for us to help the very least of these, we have to draw the line in the sand somewhere. Unfortunately, our patient landed right on the wrong side of this and pretty much, there wasn't much we could do to help in the way the patient wanted.

And so. I stood in front of Kristi's desk talking about all of this and picking her brain about what to do. And she was at least able to locate some patient assistance programs on the blood pressure meds and lists of a few medications at pharmacies with fixed prices. But then we talked about the diabetic supplies that the patient would need for things like testing blood sugars and injecting insulin.


So I took this picture of Kristi right in the moment where we all realized just how little slack people with low incomes get when it comes to something like diabetes. I mean. . .it already sucks to have diabetes, but this? This just makes it suck monumentally more. See, Kristi was looking at a screen that compared costs between certain diabetes test supplies and others. And it was dismal.

Even with "the hookup" from a special coupon, all of the supplies would run close to $100 dollars per month. $100. A straight up Benjamin Franklin one hundred dollar bill. Seriously? How in the HELL is this patient supposed to come up off of that much money for that AND eat? How.

Now. Can I just say that I don't have any prescriptions that cost me that much -- but when I did briefly take Nexium and it cost me like fifty-something bucks, I was LOSING MY MIND about it for an entire month? You'd better believe I was. And every single time I go to get some allergy medicine, I spit a little fire at the counter, too.

Man. A HUNDRED BUCKS? Dude. $100 is a lot of money. Especially for some strips and some syringes, man. So how you blame somebody for doing rock, paper, scissors when it comes to something like this? Like seriously, how can you? And, real talk, how can you even blame somebody for saying "bump it" when it comes to testing blood sugars since the strips cost a grip?

Answer: You can't.

Yeah. So here was the moment where we were all frozen in this sobering reality. Staring at that screen and wishing for a pop up with Oprah saying, "YOU GET INSURANCE! YOU GET INSURANCE! YOU GET INSURANCE!" Uuuuh, but yeah, it never happened. And the look on Kristi's face tells it all. I swear to you that right inside this moment every person there felt so helpless and discouraged. I am certain that I am not the only one who wanted to cry. I know that for certain.

Man. Here is a person who is putting on a uniform and working with greasy food all day. Someone who is dealing with demanding people and attitudes and anything else you can think of. All in an earnest effort to make a dollar out of fifteen cents.

So the very, very best we could do was this:

  • Patient assistance meds through a pharmaceutical company 
  • Medications off of the "four dollar list" at WalMart and similar places.
  • A suggestion for the least expensive testing supplies based upon our research. 

And you know? It was still dear (in price,) as my mom says. Otherwise, it wasn't dear at all.

Yeah. I'm not even sure what my point was in telling you about this. I guess I just want to shine a light on the every day struggles of people who are out here slugging it out and trying to make it happen, man. And how many things stand in the way of them going to their full potential.

"I asked for them to keep my salary where it was, " the patient said, "but they won't do it. When you been there a certain amount of time, they got to raise you up some." And honestly, all I could say to that was one word that I kept to myself.


"Seem like you better off quitting and getting disability," the patient added.

Which broke my heart even more because, in this instance, it almost was completely true.

Look, man. All I'm saying is this. It's people out here struggling. And they are not lazy or shiftless or any such thing. A lot are just resource poor or folks who made it as far as tenth grade without being able to read--meaning someone looked to the side and just nudged them on ahead. Like my patient today. Which is a whole separate issue, but still an issue. I'm just saying. It's rough out there, man.


Happy Monday.

Now playing on my mental iPod. . . . .

And check this out. . . I haven't seen it but TOTALLY want to. This is the reality that we see every single day.


  1. Heartbreaking. I had a similar situation yesterday with a homeless family. Besides taking them home with me, their only option was "P'tree and Pine" shelter. Most of the homeless I work with sleep on the streets instead of going to that shelter. Prayers lifted up.

    1. Ptree and Pine is a rough place!! Have you tried The Garden in Smyrna? A good place for families (though if a man is involved, he would be placed somewhere else).

    2. Yeah, Peachtree and Pine is tough. Fortunately, my patient had a home but it's such a hard situation.

    3. Annie, yes, I am familiar with The Garden, however, the family wanted to stay together and they wanted to stay near a MARTA line.

  2. The "bubble" in Washington D.C. have absolutely positively no idea how it is for the rest of us....and I include myself in this because we are all just one step away from being your patient in real life.

    1. Yup. I was thinking: It would be good for this patient to go and ring Mr. Romney's doorbell dressed in that work uniform with a prescription bill.

  3. This is the reality.
    The stories I could tell...
    And that's from the people I love the most who work the hardest who cannot afford health insurance.
    It's all effed-up and you know it and I know it.
    And until we get some damn universal health care in this country it's going to be that way. That's what I think.

  4. One of the best things I do at my job (in my opinion) is bring a poverty simulation to campus a few times a year. In it students from across campus (not just med students) are given roles as family members and their charge is to make it through the "month." They must pay bills, access social service agencies, buy food, medicine, etc. I believe it is a real eye opening experience for them. It is my hope that the simulation will help health care providers of all types become more empathetic and understanding toward what many of their patients in one of the poorest states in the nation face on a daily basis. "Non-compliant" has long rubbed me the wrong way - I find it to be overused and many many times incorrectly used. Many patients aren't being defiant in not filling prescriptions. They are indeed playing rock, paper, scissors with their health and health care often loses every round. Anyhoo, I'm rambling. I don't have an answer to this issue, but I do pray for all who go to work on a daily basis, hustle hard for their families, and still cannot afford the medicine and supplies they so desperately need.

    1. You know, I never thought about how offensive "noncompliant" can be as a term. It is loaded with judgement, though. I'm glad you shared your perspective and your experiences. That sounds like an amazing exercise.

  5. Welcome to my world. I make quite a bit above that 200% line, and I have insurance. But medical care in itself is expensive, and I take 16 different medications a day. Some of them multiple times. If they weren't generics and if Publix didn't give away metformin and lisinopril I'm pretty sure I'd be deciding which ones I could afford. When diabetes educators say that the cheapest strips are unreliable, I say that they are better than not testing. And I have tested them against the expensive strips without seeing much difference.

    I fear ever being told that I need insulin. I shudder when my son tells me how much a month his wife spends on it. That is what motivates me to watch what I eat and exercise. I want to push that day as far into the future as possible.

    1. Wow. Keep on fighting the good fight, my friend.

  6. I will make $22,315 this year. While I am uneducated in terms of academia I am far from being illiterate or pre-verbal. Or dumb. Before I got laid off from my blue collar job I was still below the poverty line. I am not lazy. I have to pay $540 a month for COBRA and $975 a month for rent and in one year COBRA will no longer be an option for me and most likely whatever Obamacare offers will no longer be an option either. We choose. Food. Rent. Or Rent. Food. The car insurance goes. The health insurance goes. We type at the library. But we are not illiterate not at all and I know you didn't write that but your portrayal of ALL THE WAY TO THE TENTH GRADE kind of pinched. Having been homeless for many years I can tell you that we were not at all stupid uneducated or however else you choose to see us. Though a lot of us were mentally ill. And a lot of us were tossed out of extremely abusive households. And a lot of us lost our jobs because of job cuts and the impossibility of finding another job.


      Whoa. Rebecca. You TOTALLY misunderstood me.

      That had nothing to do with me believing that all people who have been homeless or who are living in poverty are stupid or uneducated. I hope and pray that anyone who has read here long enough knows that about me. I apologize for coming across that way and for the pinch and/or hurt you felt when you read those words.

      Here is what I meant: This patient was failed by . . . I don't know. . the education system, the government, and just period. I was frustrated because my patient told me that every year she'd just been "pushed on through" even though she couldn't read. I didn't elaborate on that because it could have been an entirely separate blogpost and quite frankly it probably will be. I was mad about that. Like, how can somebody make it all the way to tenth grade without somebody sounding an alarm because they can't read? So I guess I was in my own head and assuming somebody could read my mind because my point was really that if ANYBODY should get a damn helping hand it's somebody who got shoved into high school because she "just got to old to be at the middle school and it didn't matter how much I didn't know, I had to go on up."

      Jesus. That was so, so far away from what I intended by that. And I deeply appreciate you being honest and respecting me enough to share that. I will be honest, too, and say that your words kind of pinched me, too. Every single thing you said I know. No, not as you do first hand, but because of my patients at Grady. Every story that I burn the midnight oil writing is--hell, the impetus of this entire blog--is an attempt to honor them. It makes me sad that anyone, anywhere would think otherwise.

      Every day of my life, I choose to see beauty--and I do. And yes, that is a choice.



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