“And they’ll know we are Christians by our love”

News item:

Workers at La Bit’s Heating and AC Services (in Mobile Alabama) have been living in fear for weeks, afraid of what 35-year-old Kenneth McGee would do next.

“They were minding their own business, and then here they are the subject of a random attack by someone who lives in the neighborhood.  And they don’t deserve that,” said Mobile County District Attorney Ashley Rich.

Workers say the bizarre behavior started last month with McGee hiding in the bushes, watching the business. Investigators say he threw a brick through a windshield and punched their mail box. Rich says McGee was released from Searcy Hospital (a state mental institution) last year when it closed, and prior to that, he had been in and out the facility for more than a decade. She believes it was a mistake to shut the facility down because her office is now dealing with people who should be in a mental health facility.

“It is very frustrating, and it’s something we’re seeing more and more of,” said Rich. “We were extremely disappointed when they closed Searcy because that was the facility closest to Mobile County.”

We, as are other states, are in a bit of a budget bind. It seems that “No new taxes” often conflicts with “services needed for the good of the citizens.” Nowhere is that more apparent than in the field of major mental illness such as schizophrenia. Most people with a major mental illnesses have done nothing to bring it on themselves, are disabled from a young age so have no money saved to pay for treatment, and may be alienated from their support system as a consequence of, well, the difficulty of coping with someone who has a major mental illness.This is compounded by the fact that folks with this disease are often stigmatized by their behaviors, so much so that the name of an asylum in England became synonymous with “uproar and confusion.”(bedlam)

The state of Alabama plays its own part in the dynamic tension between the needs of the state and the desire of the people not to pay for needed services. A suit filed in 1970 (Wyatt vs Stickney) became a landmark ruling that created a mandate to actually provide treatment for folks with mental illness who are held for treatment. The attorney for Ricky Wyatt, the 1970s plaintiff, alleged the following:

that patients received inadequate treatment and that the hospital was understaffed and underfunded. Of its 5,000 patients, 1,600 were geriatric patients and more than 1,000 were mentally retarded, both groups receiving custodial care but no psychiatric treatment. In terms of staffing, the hospital employed 17 physicians, 12 psychologists with varying academic qualifications and levels of experience, 21 registered nurses, 13 social service workers, 12 patient-activity workers, and approximately 900 psychiatric aides to treat the 5,000 patients. The employees whose duties involved direct patient care in the therapeutic programs, however, included only one clinical psychologist, three medical doctors with some psychiatric training, and two social workers. Alabama’s daily expenditure per patient was $6.00, with a daily food allowance of less than $0.50, compared to the national average of $15.00 a day

The case lasted 15 years with appeals and resulted in the Department of Mental Health operating under an injunction which lasted until 2003. At that time Alabama was found to be in compliance with the “constitutional right of civilly committed mental patients to receive adequate treatment” and the case was closed.

In 2009 (6 years after federal oversight ceased), the budget cuts started.

From 2009 to 2012, Alabama cut its total general fund mental health budget from $100.3 million to $64.2 million, according to NAMI. Only South Carolina (39 percent) experienced a deeper percentage of cuts. Medicaid is the largest source of financing public mental health services, accounting for nearly 50 percent of all public sector spending. NAMI argues that although using Medicaid is a laudable strategy, there are millions of individuals with serious mental illness who do not have access to Medicaid.

When the cuts began, it was clear that indiscriminate cuts would lead to problems:

Switching mental health care to community programs is a good idea “as long as enough funding comes to the community to support the lack of having institutional beds,” Tuerk Schlesinger, CEO of AltaPointe Health Systems in the Mobile area, told AL.com last February. Without that support, the community won’t be able to care for patients previously staying in state hospitals, Schlesinger said.

Although the Mental Health Commissioner could not be reached for comment regarding Mr McGee’s case, he was quoted in 2012

The future of mental health emphasizes greater independence for the consumer, then-Alabama Department of Mental Health Commissioner Zelia Baugh said at a November 2011 town hall meeting in Mobile.

“People can always eat,” Baugh said, “but if you teach them to fish, that’s a life lesson.”

Isn’t that from the book of Hezekiah in the Bible? No, wait, I’m thinking about the story about the loaves and the fishes…Jesus FED people fish!

What do you see?

I presented this patient in an article I wrote for a local media outlet:

Mrs. M. is a 51-year-old widow with two teenagers who worked as a short order cook until she was 50. She knew diabetes was a possibility, partly because she was a little overweight but mostly because it runs in her family. She may have even been told she had it once or twice but she didn’t go to the doctor regularly until after her husband died when she was 48 and she became eligible for Medicaid. While a lot of people can suffer from diabetes for years without having complications, Mrs. M. began suffering complications soon after her diagnosis. She developed neuropathy (numbness) of her hands so bad that she could no longer cook and became unemployed. Last year she developed chest pain that was due to blockages in her heart that were not operable. She also suffered greatly from heartburn but like many people couldn’t tell the difference between these pains and her heart pains so each time would call for an ambulance. She made multiple trips to hospitals. For each of these episodes she would be treated either in the emergency room or be hospitalized and would have a heart catheterization. Her income was only $8000 last year so her family was eligible for Alabama Medicaid. Medicaid paid the hospitals $420,000 on her $2,000,000 bill this past year. Alabama’s share of this was $140,000. She paid no taxes.

I wrote this to create a contrast between a Medicaid patient’s actual care in the current inefficient, fragmented system as compared to what the world of the possible might be under Obamacare if fully implemented:

Mrs. M lost her husband and took a job as a short order cook. She had previously had health insurance but now, because she is not making above the federal poverty guidelines and works for a small company, is on Medicaid. She has been seeing a health professional regularly because of her family history of diabetes and can continue to see her even with the change in insurance. She is working hard and doesn’t diet or exercise as she should. About a year ago she was told she has pre-diabetes. She was placed on a mild pill to control her cholesterol but more importantly was offered nutritional services and some support to help become more physically active. After losing 20 pounds, her blood sugar and cholesterol normalized and she has been off all medication for a year. The office calls to check in on her every month or so. For the past year her health care costs were $200 (2 office visits and a chronic care management fee paid to the doctor’s office). The state of Alabama paid $20 towards this. Mrs. M. paid $900 in taxes to the state of Alabama.

What surprised me was the intensity of the response to the scenarios. The worst was a person who felt that we should allow folks too poor to pay for their own health care to die. She believes that by providing this patient access to effective government funded healthcare we condemned an innocent non-poor person to a shooting death by the Medicaid recipient’s (sociopathic) children. This person actually signed her real name.

I was reminded by a former resident of the Incidental Economist blog (found here). They analyzed the Oregon Medicaid study in much more depth than I have and their complex read and my superficial read are in agreement. Access to healthcare through Medicaid insurance is an unmitigated good but the study is underpowered to detect how much of a good.

The most interesting observation they made relates to the interpretation of the study by the press and the public. If you believe, in your heart of hearts, that your life expectancy should not be dictated by the zip code you were born in and that we as Americans have a responsibility to our fellow citizens then you tend to cite the social determinants as a barrier and see the ACA as an imperfect means to begin correcting the inequities. This study proves that after 2 years of health care coverage people have an  improved sense of well-being  If you believe, in your heart of hearts, that health care is a service delivered by entrepreneurs to wealthy people or delivered as charity to the deserving poor, you cite Robert Sade and point to this study as evidence that health care access is not always associated with excellent health. This study proves that giving health care access to poor people is throwing good money after bad.

I suspect you can tell what the ink stain looks like to me.

Fan mail

Got this in my e-mail yesterday -

I refuse to raise my BP by stating all the abuses I see and have seen by those who are gladly using my tax dollars.  My family and plenty of other tax payers freely give large amounts of money and time to help those who are less fortunate, and we definitely need to help those who are truly in need.  It would be nice if just once, Libs like yourself would write about how we can move people off of Medicaid or at the least prevent having to use as much taxpayer money for 100% preventable medical expenses. How about some personal responsibility?  I’ve read several of your opinions,  can you just once write about how we can prevent the growth of our entitlement system and those who think they are entitled to free services? Like you said, these services are not free, the rest of us are paying for them and ourselves, and many of us are sick of paying and paying.

How about it, guys, any ideas?

Is “screwed” a bad word?

Average Doctor: What we need to do is repeal Obamacare and start over.

Policy Wonk: The Congress can not overturn the aging process, or the rise in chronic disease. Our care is high-cost and low quality care, and politicians are discovering there is no political constituency or market demand for this. Employers and other large purchasers of health care will  no longer write open ended checks. The right strategy, regardless of the future of reform, must be driven by what’s right for the patient. So, then, if not through Obamacare how would you fix the heath care system?

Average doctor: We practice way too much defensive medicine. If medical malpractice reform was enacted we could pay less for insurance and doctors would be able to practice medicine like in the old days and do what is good for the patient.

Policy wonk: OK, that’ll reduce the total cost by about 1%. The medical malpractice “crisis” is here. in large part, because the system fails patients.  Defensive medicine is tough to define and tends to exist only in the eye of the beholder. By most estimates we could reduce health care only by another 2%. Got any other ideas?

Average doctor: The insurance companies are making too much profit.  If we took money away from the insurance fat cats health costs would go down

Policy wonk: Let’s say we take away all insurance “profit.” Let’s even say we take away the cost of administering insurance. That would reduce our bill by $11 billion. Real money, except that the total health care spend is almost $3 trillion. At most, if we went to a single payer, VA type system, we could reduce administrative costs by 7%. Really want to go there?

Average Doctor: It’s big pharma. We need to rein in those drug companies.

Policy wonk:  Partly, but outpatient prescription drug costs have actually gone down in the last couple of years.

Average Doctor: It’s those patients who are reading stuff on the internet, then. They demand all sorts of things and if I don’t give it to them someone else will.

Policy wonk: Partly, but most people, though they may demand it, don’t get much. Half of all Americans spend less than $300 in an average year. 1% spend $90,000 (20% of the spend) annually.

Average Doctor: So how do we fix the problem?

Policy wonk: Look in the mirror. You collectively order too many tests on the top 20% of the spenders and often for the wrong reason. When doctors’ groups warn patients about 100 things that are being done by doctors that cause harm, you folks have a problem. You pick expensive medicine for chronic conditions when cheap medicine will do. Taking Nexium, the number one prescribed anti-acid drug, for GERD is attacking a flea with a sledge hammer for most people. The generic is just as good. Most people should try taking. It is much safer and just as effective. I’ll admit that people are getting older and fatter and there are some regulations that make it difficult for doctors to work together but, for the most part, the problem is you guys and the way you are paid. Our fee-for-service method leads to bad medicine.

Average doctor: What we need to do is repeal Obamacare and start over.

Most of this taken from the Institute of Medicine workshop on Delivering Affordable Cancer Care in the 21st Century.  

Those Irish have a saying for everything

Death is the poor man’s doctor

Irish saying

Out this week was an analysis form the group in Oregon regarding the randomization of thirty thousand ”Medicaid lottery” winners. Medicaid coverage did not reverse the course of their diabetes or hypertension in the four years they have been covered. Good health care requires more than access to insurance coverage. It did increase visits to primary care. The winners did not use emergency rooms more nor were they admitted to hospitals more frequently. Medicaid coverage did accomplished a couple of things for these folks:

Medicaid coverage resulted in an absolute decrease in the rate of depression of 9.15 percentage points (95% CI, −16.7 to −1.60; P=0.02), representing a relative reduction of 30%.

And possibly related

Medicaid coverage led to a reduction in financial strain from medical costs, according to a number of self-reported measures. In particular, catastrophic expenditures, defined as out-of-pocket medical expenses exceeding 30% of income, were nearly eliminated.

Also out this week is one of the more sobering statistics from the “Great Recession,”  published this morning:

The suicide rate among middle-aged Americans climbed a startling 28 percent in a decade, a period that included the recession and the mortgage crisis, the government reported Thursday.

The trend was most pronounced among white men and women in that age group. Their suicide rate jumped 40 percent between 1999 and 2010.

Why did so many middle-aged whites — that is, those who are 35 to 64 years old — take their own lives?

One theory suggests the recession caused more emotional trauma in whites, who tend not to have the same kind of church support and extended families that blacks and Hispanics do.

The economy was in recession from the end of 2007 until mid-2009. Even well afterward, polls showed most Americans remained worried about weak hiring, a depressed housing market and other problems.

Related? I guess we are about to embark on a much larger experiment based on which states opt into Medicaid expansion. You gotta love science!

 

 

 

I just saved you another $50

We have a new Publix in town and so I am now an unwilling target of the Publix-Walmart price wars.  Where I grew up, the Winn Dixie was our neighborhood store. My parents bought a house in the “first tier” suburbs in Baton Rouge and a suburban-type shopping center had sprung up to service the neighborhood when I was about 6 or 7. Before that, our shopping was done at the A&P “over by campus”  but we had no brand loyalty and the convenience of local trumped almost everything else. By the time I was 8, I was able to ride my bike to the store and bring home a half gallon of milk after a mandatory stop at the TG&Y. I don’t recall my mother price shopping much although I do remember when “store brands” became an option and we children had to argue for value over volume when it came to things like Pop-tarts. When we went and visited my mother’s family in the rural town of Pontchatoula, we would go shopping at Bohning’s for a very different experience. In that store, many of the staff knew my mother (even though she had been away for over a decade) and the visit was an important part of the store experience. At least for my mother it was, to be honest I was a little (well, OK, a lot) bored.

For many today, grocery shopping is a very different experience, mostly as a consequence of Walmart. In 40 metro areas in the United States, Walmart accounts for over 50% of the traditional grocery market and nationally it accounts for 25% of sales. This is problematic in two ways. One is that they are forcing out the last vestiges of personalized service such as I had experienced at Bohnings. Much worse, however, is the impact on the food chain

The real effect of Walmart’s takeover of our food system has been to intensify the rural and urban poverty that drives unhealthy food choices. Poverty has a strong negative effect on diet, regardless of whether there is a grocery store in the neighborhood or not, a major 15-year study published in 2011 in the Archives of Internal Medicine found. Access to fresh food cannot change the bottom-line reality that cheap, calorie-dense processed foods and fast food are financially logical choices for far too many American households. And their numbers are growing right alongside Walmart. Like Midas in reverse, Walmart extracts wealth and pushes down incomes in every community it touches, from the rural areas that produce food for its shelves to the neighborhoods that host its stores.

Walmart has made it harder for farmers and food workers to earn a living. Its rapid rise as a grocer triggered a wave of mergers among food companies, which, by combining forces, hoped to become big enough to supply Walmart without getting crushed in the process. Today, food processing is more concentrated than ever. Four meatpackers slaughter 85 percent of the nation’s beef. One dairy company handles 40 percent of our milk, including 70 percent of the milk produced in New England. With fewer buyers, farmers are struggling to get a fair price. Between 1995 and 2009, farmers saw their share of each consumer dollar spent on beef fall from 59 to 42 cents. Their cut of the consumer milk dollar likewise fell from 44 to 36 cents. For pork, it fell from 45 to 25 cents and, for apples, from 29 to 19 cents.

So, I looked critically at the Walmart ad in our local paper and it struck me that the savings of $36 on a $150 basket was a little artificial. Sure, they have great prices at Walmart on Coca-Cola Cherry Vanilla Soda ($1.50 cheaper than Publix).  Also, if I bought 4 different boxes of sugary cereal with the word “clusters” in the title every time I went shopping I would certainly like to save a dollar on every box. Given that 32% of Mobilians suffer from obesity, I hope we are learning to make better selections. For example:

• We could purchase a reusable water bottle and drink water instead of sodas 
• Perhaps we could try healthful (and inexpensive) breakfast on the run alternatives such as a peanut butter and banana smoothie to substitute for sugary cereals
• Maybe entertain alternatives to the chip food group
• My wife and daughter took up cookie baking to satisfy our  sweet tooth or better yet you could go without if you are trying to lose weight. If you don’t keep it in the house you can go out and get something sweet on occasion as an expensive treat.

There, saved you an extra $50. Go and spend it on local produce at a farmer’s market (if you need to find one near you, click here)..

My questions for Mobile’s mayoral candidates

My wife, Danielle Juzan, has a local political blog called “Bear Left.” She recently posed some questions for our mayoral challenger (one Sandy Stimpson), found here.  That got me thinking of what questions I would like to ask candidates for Mayor of Mobile. As a health professional, my only questions would be about health:
Gentlemen, Alabama is #45 in United Health Care Ranking and Mobile County is #45 in the state. Mobilians are more likely to be disabled than the rest of the state. From CDC data  6.5% of Mobilians have had a stroke (highest in the country, mean 2.5%), 31.4% have limited mobility (mean for US 18%), 14% require equipment for mobility (mean for US 18%). Among other diseases, the self-reported prevalence of diabetes is estimated to be 13% (US median 8%), self-reported hypertension 36% (US median 34%), self-reported coronary artery disease 11% (US mean 6%), arthritis 33% (US mean 26%). In the Gallup-Healthwise wellbeing survey, we came in very close to the bottom (#3 from there, in fact).

My question for you, Mayor Jones, is that you have had 8 years to attack our health problems and things have gotten worse, not better. I served on your transition team and we identified these exact problems 8 years ago. Most of the problems I cited above are a direct result of obesity, sedentary lifestyle, and tobacco use. With the exception of the poorly enforced tobacco ordinance (to my eyes, as one who frequently dines in downtown Mobile), what have you done to alleviate the problems of obesity and encourage physical activity? Please cite specific examples of how the solutions we identified eight years ago have been implemented.

My question for you, Candidate Stimpson, is as follows. A sickly workforce is going to be unattractive to companies looking to start up here in Mobile, no matter how small. Predictors of wellness are not numbers of hospital beds (of which we have too many) or numbers of heart surgeries done (also too many) but numbers of people who wake up every day not in pain, able to work. This requires not just “bike paths” but access to quality primary care (of which we don’t have enough), walkable neighborhoods (of which we are woefully lacking), high quality food (Mobile is not lacking food deserts), and safe places for activities for our children so that they will learn healthy behaviors. Clearly our Mayor has not taken advantages of the last 8 years to accomplish this. What concrete tasks will you commit to so that 4 years from now we will have reduced our obesity to below 25% and the number of sedentary individuals to below 25%?

The new ship’s captain or “Doctor Dunsel”?

Rick Blaine: Yes. I guess it is too far ahead. Let’s see. What about the engineer? Why can’t he marry us on the train? Why not? The captain on a ship can. It doesn’t seem fair that. Hey, what’s wrong, kid?
Ilsa Lund: I love you so much. And I hate this war so much.

Casablanca, 1942

Being a ship’s captain probably used to be so cool. Dining with the important guests. Yelling commands during exciting storms. Marrying Humphrey Bogart and Katheryn Hepburn types who were tired of that “crazy old war.”

Life onboard a ship has likely been romanticized ever since people traveled from one place to another by boat. Oh, sure, there are stories like Billy Budd and Mutiny on the Bounty but the romance of the sea was always there, at least to those who were not actually at sea.

In an old, old (1960s) Star Trek episode, a computer is placed on the Enterprise and given full command. Kirk is placed on board with a skeleton crew and the computer (remember, it could talk) is given full control. Kirk, accepting of his fate, is even called Captain Dunsel by his colleagues, a term meaning he serves no useful purpose (such as teats on a bull). Just as Kirk finds his peace with the new Star Fleet technology (and, as always, saves the Enterprise), today’s ship captains have done so as well.

The current life at sea is it is a lonely life at best. My department cares for some of the merchant marines who come through Mobile. The large container ships typically have only 12 crewmen and no passengers and are on-board a vessel over 400 yards long. There are likely over 10 different languages among the 12 crew, and so dinner time likely has limited shared conversation. They are with each other at sea for months at a time and as a rule spend less than 24 hours in port. The Captain has the responsibility for keeping this team working in an orderly fashion. Interestingly, the Captains who have come to our office for care seem to like their job. They, as a rule, smoke too much (many are Greek). Not a life I would choose for myself but one that carries responsibility, provides a challenge, offers freedom from direct oversight, and commands respect. A job that is sought after by many. Not one that I’ve met feels like a “Captain Dunsel.”

The role of the physician is now changing in our health care system. The New England Journal of Medicine has posted an article this week about the changing role of physicians. They cite the current situation as untenable and point out that the alternative “usually comprising some combination of alternative sites of care or caregivers, new care processes, and enabling technologies” depends on “two local factors: effective care teams and good management of local operations (“clinical microsystems”).” We have the opportunity to be a positive force  or we can continue to perform poorly and blame others.

Just as there is no “I” in team, there is no team based care without patients. Trying telling this to a Doctor Dunsel. “Our great care,” so the conversation goes, “is wasted on crappy patients.” There has even been a discussion amongst certain academics that we may have a created a super-race of non-compliant patient so self destructive that they can overcome even the best of care.

When trying to sell the benefits of team based care, Doctor Dunsel will tell me “I would love to be a part of a team, it’s the staff/ancillary personnel who are the problem.” Non-physicians’ contribution to care quality tends to be undervalued . The belief is that the great doctoring done by the smart doctor is lost in the incompetence of others. Outcomes measures and benchmarks, therefore, will never work.

So, just like the ship’s captains don’t do a lot they used to (including perform marriage ceremonies), physicians are going to have to come to grips with our changing status and roles. Physicians in the new model will need to “focus on promoting collective action, ceding control to the team, and showing the way by asking others how to get there.” The New England Journal article points out that these changes will be difficult

This model of clinical leadership runs counter to much current practice. [It is]  contrary to mainstream medical training and culture and the current tort environment. In many places, accepting a clinical leadership role brings a loss of status and income as well as disdain from peers.

To avoid becoming “Doctor Dunsel,” we need to embrace the concept of team. Back to the New England Journal article

Without formal authority, the only tool that clinical leaders have is their behavior: what they say, how they say it, and how they model good practice. The choice of language — expressing the team’s purpose in terms of creating value, curing disease, preventing harm, and caring for patients — and even tone of voice are essential leadership tools.

Instead of questioning how we can maintain the status quo, we need to ask the following of ourselves and our peers

“What are we trying to achieve?” “What is the best way to achieve it?” “Are we getting the desired results?” “What can we do to get even better results?” And “are our systems keeping patients safe?”

Don’t hold your breath Alabama, but…

From al.com, dateline Montgomery 4/17/13:

Health committees in the House and Senate today approved an overhaul of Alabama’s Medicaid  program.

The bills would revamp the way the state delivers services in the healthcare program for the poor, changing from a fee-for-service model  in favor of a  network of locally run managed care organizations.

Turns out, Dr Williamson didn’t even sugarcoat the truth

State Health Officer Don Williamson said the organizations will have financial incentives to correctly manage patient care to decrease expensive emergency room visits and other costs.

He said it might also include wraparound services and some out of the box thinking. Williamson gave the example of a patient in another state who kept having heat-related medical visits so the RCO ended up buying the person a window unit air conditioner.

“I assure you it was a lot cheaper than a ER visit,” Williamson said.

Williamson said federal rules will still apply so the organizations can’t try to save money by skipping out on covering mandated services.

What impresses me even more is that, as of now, we are actually well ahead of our sister state to the west in working through our Medicaid problems.

[Mississippi Democrats] say they want a debate and vote on the Medicaid expansion before they’ll reauthorize the whole program. But right now House Republicans aren’t giving it to them. Speaker Philip Gunn intentionally blocked a Senate-passed reauthorization bill that included a section in which Democrats could have proposed the expansion. Instead, he pushed a different reauthorization bill without such a section, and that’s the one that Democrats killed last month. Now each side is settling in and watching the clock tick toward that July 1 deadline.

Would Mississippi Dems really let their state’s single biggest entitlement program expire just to make a philosophical point? As Moak points out, they’ve done it before. In 2004, the GOP-led legislature passed and then-Gov. Haley Barbour signed legislation that significantly reduced Medicaid eligibility, removing 65,000 older and disabled Mississippians from its rolls. Later that year, Democrats pledged to block reauthorization of the State Department of Human Services, which houses the Medicaid program, unless Barbour allowed them to undo the cuts. Barbour refused, and the department’s authorization expired in late 2004, forcing Barbour to seek a court order that would allow the agency to keep operating.

You gotta love the Deep South!

I hope Alabamians are ready for this

There is generalized agreement in Alabama that Medicaid is broke. The governor, through an appointed commission, has established a blueprint (details found here) that is being made into legislation allowing care to transition into “regional care organizations” that would allow better, coordinated care to occur at with grass-roots input.

This legislation is modeled  on a program already established in Oregon. The New York Time has helpfully (?) provided a story so that Alabamians can see what they are potentially getting into:

Oregon and the federal government have wagered $1.9 billion that — through a hyper-local focus on Medicaid — the state can show both improved health outcomes for low-income Medicaid populations and a lower rate of spending growth than the rest of the nation.

How does this work, you might ask. A common component takes on the reality that our health care system is unusable by the people who need it the most, those who are chronically ill:

Hands-on work with patients is common to all the efforts, including one that is using “patient guides,” to talk through care options with people who stack up in emergency rooms with often routine medical problems.

Whats not to like about that, you say? The devil is in the details:

Fifteen Community Advisory Councils have been established across the state, charged with setting local goals. One of them, around the college town of Eugene, will take aim starting July 1 at smoking by pregnant women, hoping to cut neonatal costs through a system of rewards, like gift cards at the doctor’s office for women who go tobacco free.

This is getting into slippery slope territory. What about personal responsibility? Don’t choices have consequences? Reading on, you can see where this approach might not sit well with the typical Alabama voter who seems to believe (based on comments to blogs and sign held up a rallies) that recipients of “charity” should be grateful for any crumbs sent their way. Oregon has put the recipients in the driver’s seat:

“One thing unique about the C.C.O. process is the degree to which it focuses on all the elements of an Oregon Health Plan recipient’s life,” said Steve Weiss, the chairman of the advisory board at Health Share of Oregon, a Coordinated Care Organization in Portland. Mr. Weiss, 70, is disabled and gets by, he said, on $864 a month.

Oregon’s governor, as an emergency room physician, sees the potential for this approach:

Mr. Kitzhaber, in an interview in his office at the Capitol, said the anecdotal interventionist health care story he imagines is that of a poor 92-year-old woman who develops congestive heart failure in a heat wave because she has no air-conditioner.

“Under the current system, Medicaid will pay for an ambulance and $50,000 in the hospital,” he said. “What it won’t pay for is a $200 window air-conditioner, which is all she needs to stay in her home and out of the acute medical system.”

Contrast this to a comment I received upon writing about our efforts for the local paper:

The current reshuffling of the Medicaid system will do nothing to change the financial dynamics of indigent care funding. The state will have the same amount of money to provide care for an ever increasing population to be covered, and a continued abuse and overuse of medical services by a increasingly unrestrained, unappreciative, irresponsible, and entitled population.

I only hope our governor, also a physician, and legislator will continue down this path, looking beyond the “common sense” of the people, and do what is right for  Alabamians.