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Why Is Healthcare Reform So Complicated?

A common question that I get as a practicing physician with a public health background is: “Why is healthcare reform so complicated?” I feel that the question of who’s responsible for healthcare payment is not always an easy one to answer. An example from my most recent weekend on call covering an academic pediatric endocrinology practice demonstrates this point:

“Bill” is a 16-year-old African American male on state Medicaid insurance with type 1 diabetes since the age of 10.  He is followed regularly every three months by another colleague in the endocrinology clinic. Review of his last several clinic notes on the electronic medical record reveal that he has been in moderate control of his diabetes on NPH/Novolog twice-daily insulin regimen. Approximately one year prior he was changed to this insulin regimen due to concerns with missed insulin shots on another insulin regimen that provided superior control but which required four shots of insulin daily rather than the two shots daily on his current regimen.

Upon arrival to juvenile detention center on Friday afternoon in relation to recent domestic charges against his mother, Bill was noted to have a symptomatic concern for hyperglycemia so he was taken to a nearby urgent care center where he was found to have a blood glucose level of 487mg/dL. This was treated with insulin followed by a discharge as no further concerns for nausea or ketones (these are symptoms that can lead to a complication of diabetes called DKA or also known as a diabetic coma).

However, upon arrival to the juvenile detention center later Friday night, Bill did not have any of his insulin/supplies and his parents could not be reached to bring his insulin/supplies from home. Given that the center had recently reduced the evening medical staffing to help cut costs, the officers brought Bill to Children’s ED. Upon arrival to Children’s ED, his initial blood glucose was 200mg/dL. He was admitted for observation and insulin administration.

As the admitting doctor faced with this dilemma, I felt that the only option was to arrange a short hospitalization where medications would be provided through the night along with night monitoring of the high glucose. Prescriptions could then be filled in the morning along with clarification of the treatment plan to the detention center’s daytime medical staff. I personally feel that this was wasteful healthcare spending as ‘Bill’s’ high glucose could easily be managed out of the hospital. However, there were not any other options beyond me driving to the detention center myself and providing the insulin/supplies and treatment monitoring in the middle of the night myself. I did not decide to do this because I didn’t feel that this action would actually fix this system problem. In this case, state Medicaid was charged for the hospitalization ($3,000).

Who is responsible for this hospitalization which was clearly not necessary?

• The family that could not be reached to get the prescriptions?
• The detention center that cut spending on the evening medical staff?
• Wall Street’s sub-prime mortgage meltdown leading to recession and large state debt that then led to the detention center’s need to cut costs by reducing medical staffing?
• The federal government for lack of Wall Street monitoring?
• Society for making this young man a “victim” of low socioeconomic status with a perpetual cycle of abuse that required him to be placed in the detention center to begin with?

The conflict between individual personal responsibility and societal responsibility is the key issue which makes healthcare reform complicated. Until there is uniform agreement on this issue, there will continue to be disagreements and conflict in relation to healthcare reform and payment.

- Jennifer Shine Dyer M.D., M.P.H.


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