Update: my lady with insurance problems

Sorry I have not been here in a bit. It seems like life is so filled that I just don't have time to sit and write. I want to give you an update on my patient who did not have enough pharmaceutical coverage. What I ended up doing was changing her HIV regimen to Atripla( a triple drug combination pill) hoping that I could get Gilead Pharmaceuticals to allow her to participate in their patient assistance program. Initially she was denied for makeing over $50,000 year. Now remember this is a single mother of two daughters. One in high school and one in college. She pays all of their expenses, education, insurance for health and auto and everything else that is costs to have children. She workes full time and makes $62,000/year. Now even making that amount of money my patient has no extra funds at the end of the month. She certainly does not have $2000,00 for her HIV medications.
We appealed with the help of my pharmacy manager (He totally rocks). She submitted all of her income and expense history and they agreed to giver her free drug for one year.
I was so thankful but also immediatley wondered what we would do at the end of the year. Would they renew???
Well I thought we would just focus on now..
Several weeks after starting the drug she developed a severe drug reaction and we had to stop the drug. I was so disappointed. I was s hopeful that we could relax for a bit. But no...
So she came in to see me with a rash all over her body and face. We had to stop the Atripla.
So now what do we do????
This person works, contributes to the system by paying all owed taxes without resistance. She wants to do everything right, everything legal.
What she decided to do was cut her hours so that her total yearly income would be less than $50,000 per year.
She will have to cut her income so that she will qualify for ADAP (AIDS DRUG ASSISTANCE PROGRAM). She will now qualify for this and I am so thankful that the state has this program to help my patient and so many of my patients with HIV/AIDS.

The situation really makes me angry. Here is a woman who is high functioning and working within the system as a tax paying member and we offer her no help. We make her decrease her income and become a user of the system in a manner in which she never planned. .
This is why we need Universal Health Coverage. People should not have to make such a compromise for health.

I have great respect for my patient. I wish she felt comfortable to make her story known publically but with anHIV diagnosis it is not really possible for her. Iwould love to take this story to the press.

Please fight for universal coverage. What would happen to you.
If I were to loose my job and Rick and I lost our coverage he would not be elgable for coverage related to his pre-existing diagnosis of diabetes. As many of you know he was in the ICU this year. That cost without insurance would of put us out of our home.. We are so close. We are all so close. Health coverage should not be a stressor in life.. It should be a human right in this great country of ours.
This story should make you just as angry as it make me.

Hope to be back soon.

internal struggle

I am having an internal struggle. The situation in Haiti rarely leaves my mind. As a health care provide my instinct is to go and be of service. Unfortunately I am not a surgeon and my particular skills are not in need at this time. BUT, I am feeling helpless and sad. I look at the images of Haiti and I wonder what must it be like. What must it feel like to watch a bulldozer come along and scrape up the dead bodies of the ones you love? What must that fee like? I can't begin to comprehend how one survives but people do. The strength of human spirit is staggering. The power to focus forward to have faith that it will, somehow, get better is fantastic.

Yesterday at work, people were complaining and I though what the hell are we complaining about. We have food, water, shelter, safety. Why is it so hard for us to remember how good we have it at ay given moment. Why is it hard to remember out own fortune? What is it about us that makes us complain and always want more?
When I look at the survivors of Haiti I am saddened but I am also thankful. To be reminded of the greatness of my life is a gift. The goal is to hold the gift as a conscious thought.

I know that in my life I must do more for humanity. I am searching for my vehicle to do so.
My job allows me to give.. but I want to do more and will search for more to do.

I am not sure how this all ties together today but these are just my thoughts. Earlier today I went to a birthday party for Kavita. She is turning one. She is the daughter of my friend Archana. It is Archanas birthday today. Te children were present and having a great time in a blessing moment. No suffering.. just play. They were surrounded by their protectors, their parents... in a world that is safe.

Juztaposed (I am not really sure how that is spelled) with the situation in Haiti. It is some childs birthday there today.. and the word it not safe. Their protectors may be gone.

Tese two situations co-exist. Both real and both valid. The difficulty for me is to keep them side by side as realities to be acknowledged. It is a strange task.

I am feeling a bit off balance.
I would ive to hear how tohers of you are feeling about all of this. Thanks

What if this were you...

I have a patient who is a single mother of two teenagers. She was infected by her ex-husband probably many years ago but she was diagnosed about a year ago. At the time of her diagnosis she had AIDS based on her CD4 count. Remember I said that one gets an AIDS diagnosis when their CD4 cells are below 200 because at that number they are at risk for developing opportunistic infections. At the time of her first appointment we had to start her on medications for AIDS and also for prevention of opportunistic infections. We choose Prezista, Norvir, Truvada, Bactrim and Azithromycin. The monthly amount for these medications is about $1700.oo. My patient has a PPO as insurance. She is self employed and works as part owner of a resturant. She did quaify for the ADAP (AIDS Drug Assistance Program) inititally, which paid for her medication but now her income has increased just above the line and she no longer qualifies. Now get this, she pays her monthly PPO premiums and it turns out that she only has an annual pharmacy coverage amount of $1000. That is yearly $1000. So as you can see she will not even get one months worth of medications covered.
So I called her insurance company (HealthNet PPO) to ask what I could do to keep this woman alive and they told me there was nothing that they could do.. there was nothing. Now remember she has a preexisting condition which prevents her from going and getting another policy. She makes too much to qualify for medical and she is not disabled so she does not qualify for Medicare.
Remembeer also that she is raising two kids. One is a stuent at San Francisco State University and the other is in high school. She pays their tuition and their auto insurance and her house payment and her daily living expences as well as health insirance, and there is nothing left over. How is she going to get the $17000/month that she needs for the medications that she needs to stay alive?
This has been burning at me since Friday when we found this out. I am so angry. Here is a woman that does the right thing. She works, pays taxes, educates her kids. And now what????
My plan is to try to get the pharmaceutical companies to sponsor her for her HIV medcications. Will they? I am not so sure.
I am sure that there are many people like my patient. Many people that make too much for assistance but can't afford their healthcare. Is this why we need public option? Is this why we must get rid of the pre-existing exclusions?
This woman should not be punished and her kids should not loose their mother.

What do you think of this???
This should piss you off.
This should make you scream.. How do we tell this woman that there is nothing we can do???

let me tell you about...

Yesterday two of my most delightful patients were in the clinic. We were talking about stuff and I asked them if I could write about them on my blog. Well, they said yes. So let me tell you of my experience with them.
I met the first one on his medical intake. He came to the clinic with the following results on his labs work. He had HIV, Hep C, syphilis and perhaps chlamydia as well. He was giggling and appeared strung out during the visit. He looked malnourished and removed. Hiding behind drugs and with friend that were hiding with him. On arrival I was actually a bit stunned at how removed and disconnected he was from the gravity of his situation. I remember speaking with the other MD about how disturbing it was to see someone so fucked up and so young. It broke our hearts and we had no idea what was to become of him.
After many months his life turned around and I was able to learn about him and his story. He tells his story so much better than i ever could but I will give you a taste.
He comes from a conservative home and town in Utah. While in HS he had a girlfriend and she got pregnant. They thought they were doing the rght thing and had their daughter and actually had another one as well. After some time.. and never having finished HS my client split with his girlfriend and left that scene and got into drugs and sex.. hugely into drugs and sex.. as a way to avoid the pain of his life.
He prceeded to get sick in vague ways and was finally tested for HIV and it was positive. This set him into another spriral of more drugs and sex...more self-destruction.
Somehow he was able to find his way out of his darkness and seek help. I cant really tell you the specifics becsaue they don't really matter. What matteres is that he was able to overcome all his "stuff", get clean, find the true meaning of his life. He is reconnected with his daughters. His Hep C is gone. His HIV is completley controlled. He had gone back to school (he is in his 30s).
He had chosen to help others deal with the same pains that he had dealt with. He is a star. He is magic and I am so proud to have wittnessed this transformation.
He has a wonderful partner that has a kind of simular story. A delightful person who felt like he did not fit in. Always tring to get others to like him.. to want him and this led him to behaviors that led to his HIV diagnosis. He too is clean and also helping others. He has a smile and an energy that speeds up my heart ever time I see him.
These two men.. both with pain as teenagers that led they astray. They did nothing wrong. They had pain and were lookinig for comfort.
I think they have found that comfort now and it is a joy to watch them thrive and grow and love.
I thank them for all that they do every day and I thank them for allowing me to be a wittness to their story.
and I told Jonathon I would say his name. Jonathon Berg. So there!
I love you guys. you make my life better and you make my job have deep meaning and you feed my soul.

Tell me... what are we missing...

Newly infected clients.. this week I had three. They are not stupid. They are regular people who got infected with HIV. One seems totally shocked.. This was not what he planned. He is a lawyer. This is not what he thought was going to happen. Two don't seem too upset about it. I get the feeling that they figured it was going to happen.. someday.
All of them understand how HIV is transmitted yet.. they became infected anyway.
Tell me.. why are people not completely afraid of this disease.
HIV is forever. Forever medications, forever infectious. Forever risk of diabetes, heart disease and cancer in addition to the illnesses that are associated with HIV itself. Forever changes to your body that are evident of HIV, that are symbols for HIV infection.
Why is sex so overwhelming that our judgment is no long is present. Where does out common sense go?
I have a young female patient . She is 19. She delivered a baby about three months ago and gave it up for adoption. She came into prenatal care very late to find that she is HIV positive. She took her medications to prevent transmission to the baby.. so far it is negative. She continues to take her meds now. I saw her today and we were talking about her plans. She has no family or real friends. She gets support from a local HIV agency who are very concerned for her but she finds then very rigid and overbearing. I asked her today what she wants to do. This is what she said.. " I want to travel around and play around until I get sick".
This made me so sad. Here is a young woman infected through heterosexual sex. She does not really know when. And now.. what is her life to become. As much as I try to tell her that she can manage this disease and live a very long time.. she just sees illness in her future.
This makes me so sad. She has kind of given up.. although she promised me she would take her medications. She also promised me that she wold come see me every three months for lab work and to let me know how she is doing.
She is a child.. roaming alone with HIV. She is beautiful by the way...
Do I think she will practice safe sex... possibly not.. she has no income, no skill, loves alcohol. A very dangerous combination.

What can we do for her?
What can we do to prevent more hers?
How can we love her but not "lock her in a box"?

Why is it OK for my young gay men to get infected as if it is going to happen anyway.. eventually?

Condoms are free and they are everywhere...
there is needle exchange or ways of cleaning needles to prevent the spread of HIV.
There is no excuse in this country to get infected with HIV.
Help me figure this out.......
what do you think???

at first it is hard and then....

Today, my patient Clyde asked me if I had written on my blog latety. I said no and thenI asked if I could write about him. He said yes and I can even use his name. I have know Clyde for several years. He arrived at the clinic in pretty bad shape, filled with denial and filled with rage. Getting infected with HIV was not part of the plan that he had for himself. He is a good ole boy, a man that was married and in with the "in" crowd in his home town. An EMT or maybe a paramedic.. working his way up in life. He married, way too young, his high school sweetheart.. The marriage lasted a bit but then Clyde discovered another way. The way of "the party" and his life took a turn.. it was really fun initially, sex, drugs, experimentation etc..... Well he made his way to California and ended up getting test for HIV at a Planned Parenthood here. He was going just to support his other friends,, those friends who had been messing around,.. too promiscuous. not him...them. And he did have a rash that needed attention.
He certainly tells his story much better than I and fortunately he does all the time as a message of prevention...
well of as you may have expected he tested positive for HIV. This was so not in the plan.. This sent him reeling even further into the party abyss. more sex without disclosure.
He would show up at the clinic not wanting to be there and angry about being there and not at all ready for help. then he would disappear,, get into more trouble and then return with various medical issues...
All along, even though he was completely frustrating there was always something charming about this man. His southern accent and smile... was sweet even when he was completely not.

One day I remember being in an exam room with Clyde and he was in really bad shape and I figured at this point I had nothing to loose so I laid it on the line. I told him that he was going to die of AIDS if he did not stop this crap. I remember telling him that I cared for him and that it was hurting me to see him like this but that if he was not going to participate in getting well then there was nothing that I could do for him so he may as well stop coming in. I think that is pretty much how the conversation went.
I had impact that day and Clyde thanks me every day.. I think through his whole initial journey no one said that they cared, no one said you will die if you do snap out of it and that when you are ready I will help you.
Something changed. Clyde got well. HE got clean .. he got motivated.. he got healthy.

Now I can tell you that Clyde has managed his HIV, he is managing his heart (the one that beats and the one that feels). AND, he is also a positive speaker in the area. He tells his story to anyone who will listen hoping that he can prevent this virus from infecting another soul. He understands, as I do, that this virus will end only when the transmission stops and not until then.
He has taken his situation and created good from it. He is not afraid to love others, to protect others.
Now he comes in, a robust smiling man that has gotten his life back. H rides a bike, he is in school.. he is beautiful.

He would be the first to tell you that the virus sucks but he is stuck with it and has now chosen to control it rather than it controlling him.. He is one of the reasons I go to work. He will save someones life with his story and his power comes from his words, his heart and his love of self and his love of others. He always thanks me for being in his life.... and I want to thank him for being in mine.
Thank you Clyde. May you live many healthy and happy years with laughter in your life.

And FYI, if you read the previous story about my son, i want ed to let you know that he is well and living the life of a freshman at UC Santa Cruz.

My dear man from Africa

Several weeks ago I told you about my older dear gentleman from Africa. He has multiple medical problems. We have been trying to get him insurance coverage because he needs a hematologist and a nephrologist (blood and kidney). Initially we are able to g et him ADAP (AIDS Drug Assistance Program). This is a state program that ensures that all people with HIV get the antiretroviral medicatons that they need. No matter your financial situation or your immigration status you will get your HIV meds.
When you get ADAP you are eligible for County innsurance (if you do not qualify for medi-cal). So all of our undocumented patient will get the county coverage. If you are here illigally you can get care. Well, my dear man was here on a tourist VISA and because her was "legal" he did not qualify. Becasue of this he has to travel back to his home country for three months and will hopefull get a visa to return. Imagine the care that will be available??????
At the clinic where I work, we have funds to provide care and labs for our clients. But, if a patient like my dear man, needs additional care it is not available.
This is really getting to me. First of all, he will not be able to get appropriate care in his home country. This dear man is very ill and because of insurance and immigration he actually may die from his illness. We have assisted this dear man with getting him enough medications to last for three months t control his HIV. THis is crucial to prevent resistance to his medications. We must also protect his kidneys and won't be able to monitor his labs for the three months that he is gone. I am so afraid for him.
I know that we have lots of feeling about covering non citizens... but this is a human being, a dear sweet man who has been infected by a horrible virus and it seems that as humans it is our responsibility to care for another human being. Bend the rules. Care for this man. In the big scheme of financial spending his needs are minimal.
I will worry for this man every day that he is gone. I will await his return and hope that he survives the madatory hoops that he must jump though. Imagine how his son feels. Imagine if this was your father. The whole situation breaks my heart.
Keep this dear man in your heart. I will let you know when he return. Hopefully he will.