Jeff Hazzard's Response to Kaizer Health on Florida's Barriers to Health Care

Dear Kaiser:

 

   I write as a semi-rural healthcare provider in an occupational health clinic.  The crushing demand for healthcare in small towns similar to this one (35,000 residents) is moving.  The lack of access to care is beyond any debate; the battalions of "medical homeless" swell in their ranks at a an astonishing rate.  We are witnessing the unraveling of a very infirm system.  Ultimately, for me, It has become an issue of conscience. 

 

   A large portion of the patients I end up caring for as primary care patients come to me for a pre-employment physical to be cleared for an unskilled labor position.  They earn about $12 per hour, and are not offered health insurance, or are not offered health insurance until after 90 days of employment, or are offered health insurance at a premium equal to 20 hours of work after taxes per month, and double that to cover a spouse or child.

 

   The three physician groups in my town charge over $100 for a new patient to be seen in their clinics.  The local hospital will not see non-emergent cases in the ER without a $150 deposit.  The health department shut its primary care clinic.  There simply is no option for care.

 

    So, I try to provide primary care myself, as well as the patients can afford.  I generally prescribe from the $4 generic medication list at Wal Mart even though medications under patent are shown in clinical trials to be superior.  I often recommend a diagnostic or laboratory test that my patients cannot afford.  I carefully explain the necessity of the indicated test and watch grown men and women dissolve into tears because they can't take care of themselves.  I have no capacity to refer these patients to specialists.  These patients are getting disease-specific treatment for diabetes, depression, recalcitrant sinusitis, generalized anxiety, hypertension, and elevated triglycerides and cholesterol.  They are not getting screening tests for cancer, heart disease, eye disease, and dental decay.  Many of them have skin cancers and pre-cancers which they cannot afford to have removed. 

 

    I see them for $35 each, and charge my cost plus 10% for laboratory tests.  I draw their blood for free.   My charges do not cover my expenses, but I try not to dwell on that thought.  I try not to let neglected chronic illnesses cause these patients to be rejected from the hiring process because I know they will be less able to care for themselves if they are unemployed.   But it is not a sustainable business model.  As the need is burgeoning, the ratio of working poor arriving to seek care continues to climb, and a disproportionate fraction of my office visits are taken up by the medical homeless. 

 

    I do this all autonomously.  I have a "supervising physician" in a nearby town, but we never speak to each other.  He is busy with thousands of patients of his own.  Frankly, I don't need to speak to him.  Primary care is well within my scope of practice for which I am educated, certified, and licensed.  And no one objects.  I'm sure the physicians in town would object if I was placed on private insurance provider panels and if I were true competition to them for more than the medical homeless.  And I suspect that, if health reform gives sudden health market value to these working poor people, my practice will become "unsafe" in the eyes of those physicians. 

 

    What I really need are the silly restrictions on my practice lifted.  I need to be able to prescribe controlled medications so I treat anxiety more effectively.  I need to be able to treat coughs and pain.  I need to be able to order physical therapy and durable medical equipment for these patients.  I need to be listed on private insurance panels so that my patients don't have to leave me when they finally get insurance.  I need to have my hands untied so I can do the job I'm educated for.  The irony is that nurse practitioners with the exact same education and certification and licensed to practice in other states have had all this red tape cut.  But none of those other states have a corrupted legislature which is, effectively, bought and paid for by the state medical lobby.

 

     Sometimes I want to video tape my patients crying after I tell them that the law won't let me take care of them even though I know what to do.  I want the legislators to hear the patients as they tell me, "they never care about the little people like us.  We don't matter to them because we don't have any power.  We don't have any money, so we are nothing."  I want to tell the patients that they do matter.  That the law considers them.  But I mostly just stand there quietly or am forced to tell them the truth, that the legislators seem not to care about them as much as power and reelection.  

 

    Jeffrey P. Hazzard, NP, Florida

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