Dr. Jim Misak’s Remarks from Cleveland March for Health: Medicaid Works!

Dr. Jim Misak, Family Physician

I am a family physician who has the great privilege of caring for patients participating in the Medicaid program.  Based on my professional experience, I can say with absolute certainty: Medicaid works.

Medicaid is the federal-state public health insurance program for the poor and near-poor.  It largely escaped notice when it was created along with Medicare in 1965.  Since then, Medicaid has grown to become the nation’s single largest insurance program.  74 million Americans are covered by Medicaid, including 1 in every 4 Ohioans.  Medicaid pays for every other Ohio birth.  Medicaid pays for more mental health and substance abuse treatment in Ohio than any other program.  And, Medicaid is the most efficient health insurer in the country, spending more of its health care dollar than anyone else on the actual delivery of health care.

Medicaid works for my patient Mary, a diabetic who lost her job, became uninsured, and could no longer afford her diabetes medications and testing supplies.  After repeated trips to the emergency room when a diabetic crisis would arise, she became eligible for the Medicaid expansion which began in Ohio in 2014.  After working with my medical team and having access to needed medications, Mary’s diabetes is now under control, she is back at work, and she says she’s never felt better.

Medicaid works for my patient Joe, who went to the emergency room with a cough and was told that a chest x-ray showed a spot on his lungs.  Uninsured, Joe went without medical care for months until the Medicaid expansion provided coverage.  After seeing me and getting the appropriate testing, Joe was diagnosed with early stage lung cancer, which thankfully was treated while still curable.

Due largely to the Medicaid expansion, the number of uninsured in Ohio has been cut nearly in half.  The costs of care for the uninsured borne by hospitals in Medicaid expansion states, like Ohio, have decreased by more than one-third.  Because of this, many of Ohio’s smaller and more rural hospitals, often the largest and best employers in their regions, have become more financially stable and better able to serve their communities.

Medicaid is funded by both the federal government and the states.  It is funded as an entitlement, which ensures that the federal government covers its share of the cost of all eligible enrollees.  This makes the program responsive and flexible.  It allows Medicaid to respond to changing needs at the state level caused by events such as a recession, an epidemic, or an aging population.

The most recent health care bill proposed a change in how Medicaid is funded, to a per-person allotment or to a federal block grant.  If enacted, such a change would not give states more flexibility, as some have claimed.  Rather, it would remove the critical flexibility already built into the program.  It would take away health care from hundreds of thousands of Ohioans.  It would force Ohio into making impossible choices between decreasing the number of people covered, decreasing covered services, or cutting payments to doctors and hospitals, making access to care much more difficult.  And, such a change would cost Ohio between 19 and 26 billion dollars by year 2025.  That money goes to pay people, nurses and nurses’ aides and housekeeping staff, who spend their money in their communities and contribute to their local economies.

We cannot let this happen.  We cannot let this vital program die a death of a thousand cuts.  Medicaid works for our patients.  Medicaid works for our hospitals.  Medicaid works for our communities.  Medicaid works for our state.  Medicaid works!


Plassing and Poverty: One Doctor’s Dilemma

I hereby authorize ­______________, my patient, to donate plasma up to two times per week.

I moved to Cleveland over the summer to start work as a full-time primary care internist. Within a few weeks, I started receiving a form in my mailbox that I had never seen during my training in San Francisco: an authorization request for my patients to donate their plasma.

By the time the fourth form came, I realized that plasma donation was more than an altruistic fad that happened over Cleveland summers. What I eventually learned was that our patients line up for hours, twice a week, to trade their time and plasma for money. The money – $20 per session – is used to pay rent or bills. The plasma is used to create expensive biologic intravenous medications like IVIG and clotting factors.

I admit I was ignorant about plassing—the colloquial name for paid plasma donation. My first step was to look at a map. I found three plasma donation centers in Cleveland, a city which counts under 250,000 adult residents. The centers are in the Cudell, Clark-Fulton, and Buckeye neighborhoods. Zero are in San Francisco. I hadn’t just looked the other way during my training. These centers are situated in the poorest neighborhoods, and while some poor people do find a way to live in San Francisco, poor neighborhoods have vanished there.

Image: No shortage of plasma donation center locations in Cleveland in high-poverty neighborhoods.
Image: No shortage of plasma donation center locations in Cleveland in high-poverty neighborhoods.

What is plasma? Plasma is whole blood minus blood cells and platelets. When our patients give plasma, a wide needle and tube is placed in their arm to draw out whole blood. The whole blood is run through a machine that filters out blood cells and platelets, then adds salt water and returns the blood to the donor. The protein-rich plasma goes to the plasma donation center. Donors go through screenings before they are permitted to give plasma that include blood tests and a questionnaire about risky behavior. In some cases, potential donors must provide an authorization form from their primary care provider, like the ones that show up in my mailbox.

The health risks of giving plasma are unclear. The American Red Cross allows volunteers to donate only once every 28 days and 13 times per year due to perceived risks of more frequent plasma donation.

In the case of plasma donation centers, “donation” and “donor” are misnomers. Each center promises $50 for each of the first two sessions, and $20 per session thereafter. The plasma centers say that the payment is compensation for the time donors spent giving plasma, not the plasma itself. That way, they can continue to call it a “donation.” The American Red Cross, on the other hand, does not offer cash for blood products, due to concern that it would incentivize donors to lie, potentially increasing the risk of transmitting infectious diseases through the blood supply.

According to an article in The Atlantic, “The Twisted Business of Donating Plasma,” the total number of plasma donations nearly doubled in five years – from 12.5 million in 2006 to 23 million in 2011. The plasma therapeutics market — sales of drugs made with collected plasma – nearly tripled from $4 billion to $11 billion between 2008 and 2014. Plasma from paid donors in the United States make up 70 percent of the world’s supply, the author writes, earning the U.S. the distinction in the industry as “the OPEC of plasma collections.”

Plassing Testimonials
Image: From CSLPlasma website, testimonials of plasma recipients

This is not a description of a dystopian future. This is now, in the community where I live and work, and likely in your community.

Have times gotten so desperate that people need to sell their plasma to make ends meet? Yes, they have.

In “$2.00 a Day: Living on Almost Nothing in America,” Kathryn Edin and Luke Shaefer write about the rise of extreme poverty in the U.S. They use census data to estimate that 1.5 million households lived on incomes of $2.00 – or less – per person per day in 2011, double the number in 1996, when welfare reform legislation was passed. The authors write about the lives of people in Cleveland, Chicago, rural Tennessee, and the Mississippi Delta who subsist on virtually no income. Plasma donation is one of their survival strategies.

Back at my mailbox, I struggle with the decision of whether to sign the forms asking for permission to take my patients’ plasma. Do I authorize an opportunity that will provide up to $80 a month for my patients who may have no other source of income? Or do I decline their request based on the shady ethics of the plasma centers and the potential health effects of losing the protein rich fluid that holds their blood cells? For most, I choose to sign.

Big-picture thoughts on a healthier region

As the star of public service commercials widely aired in Boston and New York City, he was filmed at a baseball field, at a swimming pool and in his shower, the monotone of his mechanical voice box describing a life forever altered by throat cancer at 39.

“I almost died,” he says in a voiceover, the camera focused on a bib around his neck to cover the hole in his throat as he showers, in one ad. “Nothing will ever be the same again.”

The ads were part of a multimillion-dollar campaign of the New York City Public Health Department that was credited with smoking rates diving from 22% in 2002 to 14% in 2014. That represents nearly half a million fewer smokers.

The fight against smoking was the opening salvo in a deliberate, 12-year movement under former New York Mayor Michael Bloomberg to change the health of New Yorkers by making it easier for people to make healthy choices. New York City leveraged the power of mass-media marketing and local government to target cigarettes, trans fats and rising obesity rates with calorie counts on fast-food menus and improved access to fresh produce.

The efforts paid off in better health for 8 million New Yorkers. Between 2001 and 2010, residents’ life expectancy increased three years, to 80.9 years, compared to a 1.8-year life-expectancy gain to 78.7 years in the United States. This was not due to poorer people moving away. New York City’s poverty rate was stable during that time.

Dr. Tom Farley, former NYC Health Commissioner, speaks at City Club
Photo courtesy of Donn R. Nottage/The City Club of Cleveland

In his recent talk at the Cleveland City Club, Dr. Tom Farley, a former health commissioner in the Bloomberg administration, said the city used a “wholesale” approach to improve the health of millions, rather than a “retail” model of one person at a time.

Changing the physical and social environment is the best way to prevent behaviors that put people at high risk for avoidable, costly and debilitating chronic conditions like diabetes, heart disease and obesity — the leading 21st-century killers. Public health interventions that reach a large population save more money — and lives — than health care that typically focuses on individuals when they already are sick, Farley said.

“We can have a pretty big impact on people by changing the world around them,” Farley said.

In a private event just before his City Club talk, Farley spoke with more than 50 Northeast Ohio leaders from government, health care, academia and community organizations. What lessons can a passionate posse of public health leaders working for a billionaire former mayor offer to improve better health in Northeast Ohio?

Think big, Farley said: “We need to think as big as the problems we are trying to solve.”

In Northeast Ohio, we have big problems. Cuyahoga County ranks 65th of Ohio’s 88 counties in health outcomes; 78th in social and economic factors related to health and 68th in health-promoting physical environment, according to County Health Rankings for 2015. In Cleveland, 19% of adults are smokers.

Better Health Partnership, which partnered with the City Club to bring Farley to Cleveland and convened the local leaders, posed a question to the group: What is the single most important thing that can be done to improve the health of the population in Northeast Ohio?

The two most prominent themes in the responses suggest a promising start in thinking big: 1) Health and equity are things we all have to think about in policies across sectors, and, 2) The importance of unified approach. Together, we are so much better when we’re less focused on competition and instead focused on population health.

“You don’t need a billionaire mayor to improve population health,” Farley assured attendees. “It takes unity of purpose.”

Could a group of cross-sector leaders come together to take bold action to prevent killer diseases that are taking their toll on Northeast Ohio?

Perhaps some airings of Ronaldo Martínez’s public service announcements would be a good place to start.

This blog entry was originally published February 22, 2016 in Crain’s Cleveland Business editorial pages. It was co-authored by Dr. Dave Margolius, MetroHealth Medical Center, and Heidi Gullett, MD, Associate Program Director, Public Health/General Preventive Medicine Residency in the Department of Family Medicine and Community Health at Case Western Reserve University School of Medicine.


Team Co-Location at Neighborhood Family Practice

Welcome to the first ever BHP blog post (name pending licensing/creative ideas). In this blog, I hope to explore issues ranging from best practices in primary care to health policy and beyond. Today’s post is based on a site visit to one of Cleveland’s own high-performing primary care practices. If you want me to visit and write about your practice, just ask!

Neighborhood Family Practice’s (NFP) Ridge Road site doesn’t look like much from the outside. It sits next to a modern supermarket in an aged strip mall. The view left, right, and up is train tracks, freeways, and Cleveland’s gray winter sky. But the inside is different; the inside is beautiful. The NFP team has designed a practice that makes team-based care possible.

Last month, I visited the Ridge Road NFP site. NFP is a Federally Qualified Health Center with four locations on Cleveland’s West Side. From its website: in 2014, their 19 providers (three midwives, seven physicians, and nine nurse practitioners) cared for over 16,000 patients. Of their patients, 82% make less than 200% of the Federal Poverty Level (less than $47,700 for a family of 4) and 10% have no insurance, in a state that expanded Medicaid. NFP is excelling in a variety of ways, but in this post I want to focus on one feature: team co-location.

The entrance of the building leads to a waiting room lined by windows on the left and a front-desk reception area on the right. The far wall is covered with sky-blue poster boards on which dozens of community members have written why they love health insurance: “I now have peace of mind.” “Because I have the right to have medical services.” “Es importante para tu salud.”


Beyond the reception area, the clinical area begins with a set of offices dedicated to mental health services. These offices – plus the occupied exam rooms – were the only closed doors I saw in the entire practice.

The practice is divided into five different teams: three teams that deliver primary care, one team that is a refugee clinic, and a fifth team that is lead by midwives for pre- and post-natal care. Each team works from a dedicated team room. Team rooms contain four or five open cubicles that line the walls in such a way that the view of each desk is unobstructed from any given seat. Instead of private offices, two providers (usually a physician and nurse practitioner), one nurse, and one care navigator sit and work together in the team rooms. Each primary care team cares for approximately 2,000 to 3,000 patients.

When I have written and spoken about team co-location in the past, I often hear the same two concerns. One, how does anybody get any work done, and, two, who — other than the wealthiest practices — can afford to remodel their practice to create team rooms?

In response to the first concern, yes, at times providers need a private space to call their patient with sad news. But most of the time, working side-by-side with colleagues invites face-to-face verbal communication, which is far more efficient than the asynchronous communication of electronic medical record messages or e-mails. Those who already work in a small open space can tell you that if a telephone call requires silence, they need only ask. Large open spaces with a dozen or more workstations create a bigger challenge to find that same silent opportunity.

The second concern – who can afford to redesign the interior of their practice to support teams – has always been the more difficult challenge. Many of the practices that I have visited either were lucky enough to inherit the right floor plan, which subsequently allowed them to become a high-performing primary care practice, or they rebuilt from the ground up, a costly endeavor.

Neighborhood Family Practice proves that team co-location can be achieved a third way, not through luck or through riches, but through vision. NFP has the vision to recognize that by knocking down walls in their storefront location on Ridge Road, they can build better teams.

What’s the payoff? Don Berwick and colleagues proposed the Triple Aim: better experience of care, better health outcomes, and lower costs of care. Tom Bodenheimer and Chris Sinsky proposed a fourth aim: less staff burnout. I think in the short run, this fourth aim is where team co-location is most impactful, creating more joy in practice.

Primary care can be lonely, difficult work. Co-location can change it to work that is shared and celebrated as a team. It may be too early to tell if NFP is closer to reaching the Triple Aim, but their personnel do appear to love what they do and believe they have the tools to do their job well. That is an aim to which all primary care practices can aspire.