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Considering patient’s rights and subsidized health care.

June 22, 2013

Since I became disabled, stopped working, lost my insurance, had to sign up for the Medical Assistance Program in my county and started going to clinics serving the “poor and underserved” population, I have experienced an infuriating loss of control over the care I receive and the providers I can see.  For one thing, the quality of the practitioners serving the underserved is sometimes somewhat less than the quality of practitioners in private practice.  I recently found out that in Texas, a foreign doctor seeking licensure to practice medicine is required to practice full time for three years before becoming eligible for a full license.

From the Texas Medical Board website:

Mandatory Service Requirement

Effective 9/1/12, physician licensure applicants who are not citizens, permanent residents or conditional permanent residents of the United States will be required to practice full time, for three years, in a medically underserved area (MUA), a Health Professional Shortage Area (HPSA) in Texas, or at a Texas institution that maintains a graduate medical education program. This is authorized by Section §155.0045 of the Medical Practice Act, Texas Occupation Code.

I am not saying that foreign trained doctors are not as good as doctors trained in the US.  Like in anything else, we all have good doctors and bad doctors, no matter where we are from.  What does strike me is that you have a captive population of doctors who may be working in an area or type of practice they don’t like and aren’t good at until they are free to do what they really want (like make more money in a private practice).  As far as I can tell, Texas is the only state with this particular requirement.  I don’t know the background behind this policy change and actually believe some good could come from requiring some degree of public service from all doctors, but I do have concerns about receiving care from a continually rotating staff of inexperienced doctors who likely don’t want to be there.

I don’t know if that is the problem in the clinic system I’ve been going to.  I do observe that the doctors tend to be young and foreign and seem not to understand the system within which they are working very well.  They seem frustrated and harried.  Really though, I think most of the problems are administrative in nature as well as there being a culture of paternalism.  For example, a patient who is covered by Travis County’s Medical Assistance Program (MAP) is assigned a primary care physician.  They are not given any choice, the physician is assigned.  The first physician to whom I was assigned turned out to be a very disorganized, rude woman who did not listen to what I said, frequently interrupting me to dispute the medical history I reported and question the medical judgement of my previous (far more experienced) doctors.  She took no comprehensive history even though mine is quite complex.  She ignored my questions.  When my husband saw this same doctor, she completely ignored his reports of unbearable back pain and handed him a voucher for an eye exam.  To change doctors, I had to make several phone calls and demand to speak to a clinic supervisor.  The second doctor is better, but still not one I would choose to entrust with my health.  At this point I have given up on seeing a good doctor or getting any kind of comprehensive care under this system.  In the words of my cardiologist, “It (MAP) is better than nothing, but not much.”

The culture in the MAP program seems to include an inherent distrust of patients.  My husband and I were never asked to complete the usual ream of paperwork detailing our medical history, medications, and review of systems.  Instead the clinic prefers to rely only on written records received from other doctor’s offices.  These records are never reviewed with the patient to confirm accuracy or even that they are actually the correct patient’s records.  The doctor never asked me for details of my history.  All she got was what I volunteered and that was limited by what I was able to squeeze into the conversation.  This led to misunderstandings such as her belief that the primary reason I requested assistance applying for the local paratransit service (pick up and drop off instead of riding the regular bus) was arthritis instead of angina pectoris.  This resulted in denial of my application because what she wrote on her page contradicted what I had written on the 3 preceding pages of the form. (Don’t even ask why she didn’t look at the other pages before filling out her part and signing her name.)

Another way in which this distrust is expressed is a requirement I was presented with at a visit with a counselor the other day.  I have been attempting to establish care with a psychiatrist in this clinic system because my private psychiatrist is retiring soon.  I was told this week that I would have to provide a letter from my psychiatrist stating that I was no longer under her care before I could even obtain an appointment with a psychiatrist.  When I said that I would not terminate care with my current doctor without first interviewing and consenting to be cared for by the clinic doctor, I was told I would not be given an appointment.  The explanation involved the standard of care requiring only receiving prescriptions from one doctor at a time.  That part is accurate, however what they are demanding I do is go for a period with no doctor and take my chances on the competence and fit of this unnamed clinic doctor at a clinic where I already know competence is not a big priority.  Of course the easy thing to do is to ask my current doctor to write the note, see their doctor, and if their doctor is unacceptable fire them and rehire my current doctor.  But why should a patient be required to do this in order to get care?  I am perfectly willing to sign an agreement that I will only have psych medications prescribed by one doctor at a time, however I am not willing to fire the doctor I have been with for 11 years in order to get an appointment with someone else sight unseen.
Patients’ rights is a concept that is loosely applied in the world of MAP/CommUnityCare.  Let me share a definition of this concept from MedLinePlus:

As a patient, you have certain rights. Some are guaranteed by federal law, such as the right to get a copy of your medical records, and the right to keep them private. Many states have additional laws protecting patients, and healthcare facilities often have a patient bill of rights.

An important patient right is informed consent. This means that if you need a treatment, your health care provider should give you the information you need to make a decision.

The key here is the right to the information needed to make an informed decision.  I cannot make an informed decision to drop my current doctor without knowing who is there to replace her.

So while discussing my objections to the fire your doctor policy with the counselor, he made the observation that feeling one does not have choices makes things much more stressful.  He then stated that I do have choices.  It turned out he was referring to another organization called Lone Star Circle of Care which also takes MAP.  I had been thinking of looking into care with them but was afraid of losing access to my medications in a switch over.  My mind was made up to finally seek an appointment.  Ok, here’s the icing on the cake:  when I called Lone Star to request an appointment, I was informed that MAP requires me to change my primary care physician assignment to them before I can get an appointment.  Then the nice young lady told me that other patients have had significant difficulty doing this and that it can take “a while.”  How’s that for a how do you do?  To leave a clinic with poor care for one that is possibly better, I have to burn the bridge with one before I can even see what the other is like. Pretty much like the situation with the psychiatrist.
Recently on a discussion forum for “preppers” (people preparing for the imminent collapse of society), I saw a discussion of signs that the SHTF (shit hitting the fan) is happening really soon.  (yes, I entertain idle fantasies of what would happen if civilization ended tomorrow) One of the signs mentioned was people accepting poor health care as a matter of course.  It sure feels like we’re there.  Guess I’d better fill the water tank and stock up on non-perishables before SHTF.
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