Jousting with idiots, wrestling with bureaucrats

For medical care you must wait

And drive clear cross the state

My patience it wears,

That Iowa cares

Is a program I just love to hate.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time position with a Community Health Center, which dropped from 54 hours a week to 40 on December 1.

At some time in the past, Iowa, to deal with the problem of delivering medical care to the indigent, instituted the Iowa Cares program.  Start with a simple idea: any Iowa resident presenting to the medical center/school in Iowa City will get the best of medical care regardless of ability to pay.   Then offer primary care entities $20 for all the care delivered at any one visit, including lab and x-ray. 

A few people smart enough to make it through med school but dumb enough to take that contract signed on.  Thus people of little means ended up driving up to 2 hours for “free” medical care.

If the person needed inpatient care, the local hospital would pressure them to accept transfer to Iowa City.  Specialty care necessitated a hefty wait, and a drive across the state.

Those patients who went onto the Iowa Cares program had little in the way of assets.  Many lacked coping skills, emotional resilience, patience, forward-planning skills, impulse control, and memory.   They drove older, fuel-inefficient vehicles.  Some ran into cancelled appointments after an all-day trip.  Many had to give up Medicaid coverage to get Iowa Cares. 

Broadlawns, in Des Moines, picked up the contract for a lot of the specialty and inpatient care, which brought the drive from 8 hours to 4.  But four tanks of gas (never mind snacks on the way) and a motel room can easily run into the triple digits, which puts the lie to the concept of “free” medical care. 

This summer, with the anticipated flowering of Obamacare, the University of Iowa announced that the Iowa Cares program would close on midnight of December 31. 

Yesterday, with less than 36 hours left in the program, a patient came in for a first Iowa Cares visit with me, at 2:15PM.  In less than 5 minutes, I knew the patient needed surgery; a 10% weight loss in 21st Century Iowa, never normal, ranked as the least of the physical findings.  No, I told the patient, the clinic 75 minutes’ drive from here hadn’t sent the information.  I called them.  The nice lady at the other end promised I could have the documents by the end of the day.  Not good enough, I said politely, I needed them within an hour, and quickly faxed a Release of Information.

Outside, snow started.

An hour later, I had the information in hand, and I had our Iowa Cares specialist start the ball rolling. We needed a full-time tough, savvy, smart person just to deal with the program.  She keeps detailed notes, and pointed to the entry where she told the original primary doc to arrange surgery ASAP; the names and the date 2 weeks prior jumped off the page at me.  I knew I’d have to tap dance and sprint to get things going before the end of the business day.

I called the doc at Broadlawns ER.  He couldn’t accept the referral, he said, I’d have to talk to the surgical subspecialist on call, but if I suspected cancer, the patient would have to go to Iowa City. 

I could marginally justify sending a patient out on marginal roads for 4 hours but not for 8.  Could I just send her to our ER in Sioux City?

No, I had to talk to the Broadlawns doc.

After wending my way through phone trees and blockers, I left my cell phone number with someone who accepted the transfer without having the authority.

The call came at 4:45.

Medical school taught me a lot of things, but it didn’t teach me jousting with idiots.  I had to learn that on my own.

I tried to break into a tirade of arrogance twice and the third time I said, “Look, just stop interrupting me for one minute, OK?  If you refuse the transfer, it works for me, I would just as soon send her up to my local ER.”

No, he wasn’t refusing the transfer.  But it took him five minutes of belittling and insulting me to accept it.

I’ve run into such resistance in the past, always in the context of doctors horribly overworked in a dysfunctional system.  Though those individuals irritate me to no end, I feel for them.

The patient left into a thickening snowstorm.  I received word today the hospital care had started and the condition had stabilized. 

But if someone postpones surgery past midnight, when the Iowa Cares program stops, I don’t know what the patient will do.



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