I'm still wondering what it is about the experience in Bhutan that makes me feel as if I tomorrow I will be waking up in that bare apartment again with the dogs in the hall, getting the space heaters going for warmth, hearing the sounds of the trumpets and monks chanting from the chorten.
It's not as if I don't enjoy being home with my wife, my own dogs and friends. It's the reentry into our health care system that been challenging.
Soon after my arrival home I attended an evening meeting at Baystate Medical Center (BSMC). Pediatricians in the Pioneer Valley are being wooed by a PHO (physian's health organization) from the Boston area, called PPOC (Pediatric Physician's Organization at Children's Hospital) PPOC is run by pediatricians. It also functions as an ACO (accountable care organization) that "manages lives"- keeps track of costs per member per month. Naturally, that has concerned BSMC, which, through it's PHO, has been the contracting organization for our group, and many of the pediatricians in the area. Will pediatricians who are part of the PPOC refer to Childrens Hospital in Boston instead of Baystate? they worry. Many pediatricians are of course attracted to the idea of a pediatrician led group, that will have this specialty at its focus, instead of having kids health as a virtual afterthought behind the cardiac surgeons and others who bring in far more money to BSMC.
Complicating matters is the fact that two months ago, Baytate was unable to agree to a contract with Boston Medical Center (BMC)- Healthnet -- the leading managed care organization for Medicaid/Mass Health in the Commonwealth. BMC Healthnet are the insurers for a third of our patients. So as of December 1, one third of my patients will no longer be able to access care at Baystate Children's Hospital. Baystate Children's Hospital has the only pediatric emergency department in our area, the only wards that admit children for hospital care, the only pediatric nurses, the only neonatal intensive care unit, and employees almost all the pediatric sub specialists in Western Massachusetts.
Adding to this disastrous situation is the fact that since Holyoke Pediatrics contracts through Baycare, all our Healthnet patients have had to change insurances or find new pediatricians. As of December 1. (Since then, there has been a month long extension of this deadline and talk of Baystate starting its own pediatric ACO).
The meeting location had been changed from a comfortable, dignified and venerable meeting room in a wing of the old hospital to what was unfortunately a more appropriate setting: a windowless featureless classroom in an office building that houses the staff of the contractors at Baycare. It's the place for bean counters.
I found myself locked out of the building. They had forgotten to keep it open for stragglers. A fellow pediatrician from another group was also locked out. I texted one of my partners Jane Cross but there was no response. The intense presentations and conversations were in full flight, and, Jane (or Dr. Jane, as she would be called in Bhutan), sitting in a middle row, was too embarrassed to make her way out of the crowded room to let me in. However, a few minutes later, a black limousine pulled up by the curve in front of us. An African American driver opened the door for a distinguished looking African American man dressed in a fine black suit. He introduced himself as a vice president from Children's Hospital (I have since forgotten his name) He was late because of traffic out of Boston. He was due to address the group shortly. I texted Jane back: You'd better come down to let us in. An important guy from CHMC is here. She came right down.
Upstairs I went looking for a rest room. My memory of the administrative offices here were correct, and my criticisms of the JDW Referral Hospital, which I wrote in my outgoing survey, were correct. JDW's clinics and inpatient areas were mostly dark, and depressing, and unclean by western standards. Yet the new postgraduate medical center building, has sunny modern offices large enough to roller skate around. Here, the opposite is true. Except for the adolescent unit, housed on the 6th floor in a dark old wing of the hospital, the patient areas are bright and cheery. The Pediatric Intensive Care Unit has shimmering colorful fluorescent lights. The brand new out patient clinic, though housed in a former warehouse district, has a bright atrium not unlike that of the Museum of Modern Art in New York. But the many offices housing everyone from administrators to telephone operators to medical records staff are mostly drab and dingy. These offices were no exception. Outside the meeting room was a buffet with crudités , mushroom and hot dog canapés, and salad, and fruit. I had a little of each.
The only left to drink was coke. I had a cup.
The atmosphere in the meeting was tense. Pediatricians and administrators from private practices expressed their frustration with the fact that some of our poorest patients were being treated like pawns in these contracting disputes, and may soon be left without adequate pediatric care. BMC Healthnet had evidently not negotiated a contract with Children's Hospital Bay either. And it became clear that the PPOC and Baycare had not been meeting together at all to try to figure out what was the best for the health of young people of Western Massachusetts but were trying to garner our contracts.
I thought of how much of the day of a doctor in the U.S. is spent worrying about the dizzying alphabet soup of agencies that manage the private health care system here. Which ACO or PPO will contract with which health insurance companies. What medicine, specialist, procedure, or mental health professional each of these companies will pay for (which is always changing). Whether our patients can afford the burgeoning copays for physical therapy and other important services (they frequently can't). And this is in Massachusetts which, with "Romneycare", the precursor of Obammacare, has better coverage than most of the nation. I thought of how a growing percentage of our day, is spent entering data to satisfy the "meaningful use" guidelines, which are often meaningless. How little how any of this has to do with taking care of sick people, or helping healthy people stay well.
Dr. Tashi and Staff in the Pediatric Intensive Care Unit
And I recalled the last case presentation I heard in Bhutan, by one of the two pediatric residents I supervised in Bhutan, Dr. Kalpina. I baby with the typical stigmata of Down Syndrome was born in a small village in the Mongar district. Since no chromosomal testing is available in the country, the diagnosis is made clinically. Like many newborn infants with Trisomy 21, the infant had troubles with sucking and feeding. He had a murmur, presumed to be a ventricular septal defect. The child also had a white blood count of 45, 000, with numerous immature forms including lymphoblasts. This combined with a low platelet count, and anemia, led to an initial diagnosis of congenital leukemia. The baby was treated for possible sepsis and observed. The white blood cell count gradually fell to a normal level, and the platelets increased; with the help of a transfusion, the anemia resolved.
Dr. Kalpina led us to a diagnosis of transient myeloproliferative syndrome, which unlike the previous fatal diagnosis, resolves on its own. I asked about getting a bone marrow aspiration, just to make sure.
"You probably wouldn't know about this", Dr. Tashi explained, apologetically. "But the family doesn't have papers" He belongs the Nepali minority, who are undocumented residents.
Unlike here in the U.S, no one calls them "illegals". They still get free health care and education. But, Dr's Tashi and Kalpina (a Nepali herself) explained, unlike Bhutanese citizens, they don't get to be sent to India for free medical care not available in their country --- like bone marrow aspirations for infants.
This was the only problem in access to care, the only thing approaching the endless complex web of insurance hassles that are part of our health care system the entire time I worked in Bhutan.
During the two months I was away, I drank water that had to be boiled, consumed produce bought from street vendors, including raw carrots and apples, drank hot buttered yak tea, and shared a traditional picnic lunch on a hot day with new local Bhutanese friends, but never suffered any gastrointestinal upset. That night after the Baycare meeting, I was sick to my stomach all night. Maybe it was bad raw carrots combined with coke. But it could have had more to do with the rot in our health care system than the rot in the buffet.
