It's all about the Benjamins, baby.

This is Kristi. She's one of the amazing hospital pharmacists at Grady Hospital. She is smart and diligent and empathic and generous with her knowledge. I stopped in her office today along with one of the residents because I needed her help.

The question wasn't about the pharmacokinetics of some drug or even about some kind of drug-drug interaction. Nope. This was question about what is, unfortunately, one of the most common things that gets discussed at public hospitals: Cost.

Okay, so check it. Grady Hospital and the handful of other safety net hospitals in the U.S. that turn no one away due to limited ability to pay has programs in place specifically for our poorest patients. That is, if you are at 200% of the U.S. poverty line or below, you qualify for a significant amount of assistance with whatever it is you need. And that? Now that is wonderful thing.

Now. If you are like me, you probably have no idea what 200% of the federal poverty level is. And maybe you are one of those people who just walks around with that kind of information in your head, but I'm not. So me? I had to look it up today. And I'll tell you why.

I saw a patient today who was sitting in front of me in a work uniform. Had worked some crazy oddball shift in order to get out in time to make this appointment with us for management of high blood pressure and diabetes. And really, this patient was super motivated, kept appointments, and went through great effort to make it over to see us.

Okay, so we check the lab results from the most recent blood draw and things look horrible. Like for real, horrible. The blood sugars are out of whack and the patient is clearly not doing what we asked at the last visit. And so we asked the patient straight up:

"What's up with your blood sugars? Is everything okay?"

"No," our patient replied, "I only take my insulin here and there because I can't afford it. I can't afford the blood pressure pills, neither."

And that was weird because this patient wasn't new to us. I mean, this patient had been coming to Grady in that same work uniform for many years. Why was this suddenly an issue?

My resident blurted out a question before I could. "Don't you have a Grady card?"

What she was speaking about was the sliding scale card given to patients with limited ability to pay. The patient gave a hard head shake.

"I used to. But my job gave me just a little bit more money so now I don't qualify no more."

And let me tell you. This patient was a hard worker. I also know that uniform was not one worn by a person who makes stacks and stacks of money. And so we talked about it and the patient said, "Essentially, I am now just over the line." Which was later clarified to be 201% of the federal poverty level. I agreed to look into what we could do to assist by talking to Kristi and also our social worker.

And so. I also looked to see what that all meant in concrete language.

Household Size	100%	133%	150%	200%	300%	400%
1	$11,490	$15,282	$17,235	$22,980	$34,470	$45,960
2	15,510	20,628	23,265	31,020	46,530	62,040
3	19,530	25,975	29,295	39,060	58,590	78,120
4	23,550	31,322	35,325	47,100	70,650	94,200
5	27,570	36,668	41,355	55,140	82,710	110,280
6	31,590	42,015	47,385	63,180	94,770	126,360
7	35,610	47,361	53,415	71,220	106,830	142,440
8	39,630	52,708	59,445	79,260	118,890	158,520
For each additional person, add	$4,020	$5,347	$6,030	$8,040	$12,060	$16,080

It gets cut off on this chart, but just know that $22,980 was the 200% marker for a single person and $31,020 for a two person household. Yeah. So my (single) patient was making like $24K per year up from like $22,500. And you know what? That patient was working hard for that little bit of money. Hard.

And so. I talked to all of the people that you talk to about these kinds of things and heard the same answers. Which essentially is that in order for us to help the very least of these, we have to draw the line in the sand somewhere. Unfortunately, our patient landed right on the wrong side of this and pretty much, there wasn't much we could do to help in the way the patient wanted.

And so. I stood in front of Kristi's desk talking about all of this and picking her brain about what to do. And she was at least able to locate some patient assistance programs on the blood pressure meds and lists of a few medications at pharmacies with fixed prices. But then we talked about the diabetic supplies that the patient would need for things like testing blood sugars and injecting insulin.

Okay.

So I took this picture of Kristi right in the moment where we all realized just how little slack people with low incomes get when it comes to something like diabetes. I mean. . .it already sucks to have diabetes, but this? This just makes it suck monumentally more. See, Kristi was looking at a screen that compared costs between certain diabetes test supplies and others. And it was dismal.

Even with "the hookup" from a special coupon, all of the supplies would run close to $100 dollars per month. $100. A straight up Benjamin Franklin one hundred dollar bill. Seriously? How in the HELL is this patient supposed to come up off of that much money for that AND eat? How.

Now. Can I just say that I don't have any prescriptions that cost me that much -- but when I did briefly take Nexium and it cost me like fifty-something bucks, I was LOSING MY MIND about it for an entire month? You'd better believe I was. And every single time I go to get some allergy medicine, I spit a little fire at the counter, too.

Man. A HUNDRED BUCKS? Dude. $100 is a lot of money. Especially for some strips and some syringes, man. So how you blame somebody for doing rock, paper, scissors when it comes to something like this? Like seriously, how can you? And, real talk, how can you even blame somebody for saying "bump it" when it comes to testing blood sugars since the strips cost a grip?

Answer: You can't.

Yeah. So here was the moment where we were all frozen in this sobering reality. Staring at that screen and wishing for a pop up with Oprah saying, "YOU GET INSURANCE! YOU GET INSURANCE! YOU GET INSURANCE!" Uuuuh, but yeah, it never happened. And the look on Kristi's face tells it all. I swear to you that right inside this moment every person there felt so helpless and discouraged. I am certain that I am not the only one who wanted to cry. I know that for certain.

Man. Here is a person who is putting on a uniform and working with greasy food all day. Someone who is dealing with demanding people and attitudes and anything else you can think of. All in an earnest effort to make a dollar out of fifteen cents.

So the very, very best we could do was this:

• Patient assistance meds through a pharmaceutical company 
• Medications off of the "four dollar list" at WalMart and similar places.
• A suggestion for the least expensive testing supplies based upon our research. 

And you know? It was still dear (in price,) as my mom says. Otherwise, it wasn't dear at all.

Yeah. I'm not even sure what my point was in telling you about this. I guess I just want to shine a light on the every day struggles of people who are out here slugging it out and trying to make it happen, man. And how many things stand in the way of them going to their full potential.

"I asked for them to keep my salary where it was, " the patient said, "but they won't do it. When you been there a certain amount of time, they got to raise you up some." And honestly, all I could say to that was one word that I kept to myself.

Damn.

"Seem like you better off quitting and getting disability," the patient added.

Which broke my heart even more because, in this instance, it almost was completely true.

Look, man. All I'm saying is this. It's people out here struggling. And they are not lazy or shiftless or any such thing. A lot are just resource poor or folks who made it as far as tenth grade without being able to read--meaning someone looked to the side and just nudged them on ahead. Like my patient today. Which is a whole separate issue, but still an issue. I'm just saying. It's rough out there, man.

Damn.

***
Happy Monday.

Now playing on my mental iPod. . . . .



And check this out. . . I haven't seen it but TOTALLY want to. This is the reality that we see every single day.