Progress Notes features doctors and medical students across the country on the frontlines of our health care system. Our views and experiences are diverse, but we share common goals and values. We speak up to move toward a future where everyone can have access to affordable, high-quality health care. Please share our posts, and follow us on Facebook and Twitter!
Great fleas have little fleas upon their back to bite 'em
And little fleas have lesser fleas, and so ad infinitum
Who knew? This famous couplet, which the mathematician Augustus DeMorgan apparently expropriated from the poet and social critic Jonathan Swift, comes from a book whose title originally (and now again) captures the essence of complex interdependency, a “budget of paradoxes”. The lines came to mind unbidden during the recent government shutdown, when I learned that in DC, where I teach and practice, hospitals were surviving on reserve funds the city tapped to pay bills normally covered by the federal government under Medicaid. By the early part of last week, those funds were nearly tapped out.
Republicans in Congress seem inclined to treat those depend upon the federal government to pay its debts as no more than pesky fleas. But for DC hospitals that provide care to a large Medicaid population, the threatened interruption of reimbursement was of great concern. Our local hospital system is already under enormous stress. With a shortage of beds, patients are “boarding” in emergency departments, sleeping on stretchers or in recliners in hallways for days on end. At my own hospital, our once beautifully appointed space now resembles a train station waiting room, with nurses, physicians, and social workers clacking away at keyboards and pleading on telephones to find places for weary patients-in-waiting. From the halls of congress to the hallways of the emergency department is a very short step, at least in this city.
Many municipal hospitals operate on a slim economic margin. If the government had defaulted on its obligations, hospitals would not have been able to pay their staff or suppliers on time. Like the bigger and lesser fleas, this process would have transferred the economic burden inexorably down a line that begins with businesses and professionals and lands squarely on the backs of patients. Delay in reimbursement would have meant more beds would close, and the people now crammed into hospital hallways would have been sleeping, or dying, in homes, attics and on subway grates.
The infinite regression of suffering that would follow from a governmental failure to pay its debts, like the bites of fleas, is something none of us, but especially those of us involved in healthcare, can ignore.
As in the rest of states using the federal government’s healthcare.gov portal to the Affordable Care Act’s marketplaces, Utahns have experienced their share of difficulties signing up for insurance. Inability to get beyond the home page or being bumped off prematurely seems to be a common complaint.
Despite the not unexpected bugs in a new and complicated information technology system, residents of the Beehive State are finding bargains and access to health insurance that was previously unobtainable. One of the most spectacular success stories is that of Phil Sherburne and his family.
Sherburne, the owner of small retail shop, could not afford health insurance for himself, his wife, and three children, for several years. After suffering a rotator cuff injury it was difficult to even find a plan that would cover him at all. He paid cash for all his families’ health care needs, including a $3000 bill his wife received after an ER visit for a gallbladder attack.
He had a heck of time accessing the marketplace. On October 1st he couldn’t get past the home page. On October 3rd he tried several times throughout the day and evening, got past the homepage, but then was bumped off. He called the 1-800 number but gave up after being placed on hold for over 10 minutes. But on October 5th he was finally successful. He found 38 available plans and found out that he and his family were eligible for a sizeable subsidy via tax credits. He considered a high deductible plan that would have cost him a mere $5 per month but eventually purchased a silver plan that, with the tax credits, will cost him $123 a month. The plan retails at $850 per month.
Once he got into the site, Shelburne was really impressed with the layout, pop-up links, and ease in comparing costs and benefit packages of the various plans. Each of the five family members required about a page of information “but once I got on to the site it took about an hour, start to finish.” He was even able to make sure his son’s pediatrician was in the plan’s network. “It was really slick,” he summarized. “Once they get the bugs worked out, it will work well and bring peace of mind to a lot of people.”
Although there has been lots of attempted and actual visits to healthcare.gov, it is difficult to determine exactly how many individuals in Utah, and in other states, have actually successfully signed up for insurance. But even if that number is currently low, there is still lots of time left for success with open enrollment available until March 31 of 2014. And as was noted in a recent opinion peace in the New York Times, folks will likely do lots of shopping before they actually buy. There were an average of 18 inquiries on the 2006-era Massachusetts Health Connector website before a person signed up for coverage.
Many have been surprised that the balky marketplace website, although generating many complaints and much frustration, has not produced much anger and recrimination. Folks have been quite patient and reasonable as they queue up to hunt for insurance. But those surprised by such forbearance fundamentally misunderstand the plight of the uninsured. Although experiencing several hours of computer bugs is frustrating, it pales in comparison to the frustration and anxiety one feels for oneself and their family when they endure years without health insurance coverage. Human beings by nature will placidly overcome multiple hurdles to improve their own and their families’ safety and security.
The official opening of the online marketplaces created under the ACA was highly anticipated- and not without its glitches, in the best sort of way. After months of foreboding press about how 80% of the uninsured didn’t even know about the healthcare exchanges, let alone whether they would sign up for coverage, websites and call centers were inundated across the country. 4.7 million unique visitors went to healthcare.gov, the portal for individuals and small business owners to find out their options under the new insurance program. For some, this resulted in long wait times or spurious website access. For others, it highlighted institutional gaps that exist for at least 15% of American adults- lack of regular internet access.
My day began with trying to sign my father up for an account on the federal exchange, as he lives in a state that has chosen not to run its own. The first challenge we encountered, on the first page we went to: him sitting in silent confusion for a moment then saying “What’s an email address?” It was then I realized that this might take a while. And here’s the thing- that’s ok. October 1st was just the beginning of a 6 month enrollment period, of the first year, of what will become a program integral to the fabric of our social structure, just like Medicare and Medicaid. These programs (among others) have become interwoven into our concept of what we as a society value and think deserves protection from the unpredictabilities and vicissitudes of both economic downturns and political volatility. The Affordable Care Act is just beginning the social and symbolic work it will do- both over the next year and the next decade.
And Americans understand this- and can be a patient people, which might surprise some of the commentators and pundits who edged toward forecasting failure after technical challenges in the roll outs. But sites were overwhelmed by a pent up demand for affordable health care coverage, a desire by millions across the country to provide financial and emotional security for themselves and their families for the time when (not if) they next find themselves in need of medical care. A narrative emerged from a panoply of community centers and doctor’s offices that people trying to sign up were eager, and while disappointed with some of the wait times, willing to wait. For the savings, and sense of security, some were willing to wait all day. Or perfectly willing to come back next week. Or the week after. Plans don’t kick in until January, and for people who may have been waiting for coverage for years- a few weeks more, after which they will have the same coverage the rest of us can enjoy, feels pretty reasonable. As one official said, this is not a sprint, it’s a marathon. But for the 5700 people enrolled as of today, it’s a marathon they’ve already won.
Utah’s Medicaid Expansion Community Workgroup has completed its work and given Utah Governor Gary Herbert several options that would expand insurance coverage for Utah’s 123,000 low-income uninsured. Unfortunately, the governor will not make a final decision about expanding Medicaid until January. Thus, the state will lose out starting January 1st on millions of dollars of available federal funds. Even more concerning, the state’s uninsured, ineligible for or unable to afford insurance in the Affordable Care Act’s (ACA) Health Insurance Marketplaces, will continue to suffer.
At the August 1st workgroup meeting, testimony and a white paper were received from Sven E. Wilson, PhD, a Professor of Public Policy in the Departments of Political Science and Economics at Brigham Young University. Dr. Wilson is also a Research Economist at the National Bureau of Economic Research and a Senior Consultant in the Utah Department of Health.
Wilson prefaced his remarks by describing himself as a “conservative economist” who believes in individual responsibility and that free market and private sector approaches to solving problems of resource distribution are nearly always preferential to government intervention. Nevertheless, he recommended that the state of Utah take advantage of the ACA’s option to expand Medicaid.
Wilson’s testimony and paper made these points. Economic analysis does more than just analyze dollars spent but must factor in a broader perspective “that includes the things that affect human welfare and happiness---things like health, suffering, life expectancy, family relations, leisure time, and quality of life.” The responsible economic analysis provides policymakers with a broad view of on-budget and off-budget costs and benefits from which they can choose. But ultimately, the policy choice is made not purely on the basis of costs and benefits but on questions of values: “what is the proper role of government and what kind of society do the citizens of the state want to have?”
On-budget impacts to the state, based on data from Public Consulting Group’s (PCG) 2013 report, are minimal when compared to the cost of health insurance in the private market and the overall impact on the state’s budget. The 10 year average cost to the state to fully expand Medicaid is $158 per patient per year with the federal government picking up the additional $3,040 per patient per year. This cost compares very favorably with the average cost of private health insurance for an individual in Utah at $4,257 and family of $11,869. After figuring that the average state budget would increase by 0.26% annually he concluded that “looking at the state budgetary costs alone, Medicaid expansion seems like a very good bargain.” And this does not even take into account the new tax revenues generated from the influx of new federal money.
He then went on to describe the off-budget benefits of the Medicaid expansion. Direct benefits to the newly insured are the most important and will be discussed below. Reduction in uncompensated care to Utah providers will save the state’s insured citizens $815 million in costs currently shifted to them. It will also likely produce efficiencies in health care as service in expensive emergency department settings moves to the outpatient arena. The $3.12 billion in new revenues to the health care industry and $2.91 billion in economic impact over 10 years, even if significantly overestimated by PCG (and Wilson goes into great detail how such estimates are problematic and must be looked at with great skepticism), will more than compensate for the estimated 10 year cost to the state of $158 million for the full Medicaid expansion. The ease in financial and emotional strain to families of the newly insured is immeasurable but certainly “exceeds the state’s budgetary costs many times over.”
Wilson also discussed possible off-budget cost of the expansion. These negative impacts may include potential disruptions of insurance markets, denial or delay of medical services to all populations of patients, increases in the price of medical services to the non-Medicaid population, and diversion of scare state resources from the needs of education and law enforcement. These negative impacts disproportionately impact the poor more than the affluent.
Next in his paper is a discussion of the concept of “consumer surplus,” which Wilson considers to be the strongest economic argument for Medicaid expansion. Consumer surplus is “the amount of money that consumers would be willing to spend on a good or service beyond what the market requires them to pay.” Consumer surplus associated with health care and health insurance is very high. As prices rise, consumer demand for health services changes little and displays the economic concept of price-inelastic demand. Even the poor are willing to pay a lot for health care; studies have shown that even those on Medicaid are willing to spend on average an additional $1,900 a year for health care services. If 100,000 poor Utahns are willing to spend $1,900 dollars a year for ten years, that is $1.9 billion of consumer surplus. So how much is insurance worth to the poor if they were not insured? Quite a lot ---and much more than the budgetary cost to the state.
Wilson argues that “if we put all the relevant costs and benefits on the table—meaning everyone’s benefits and everyone’s cost are given equal standing--the benefits to Utahns of using federal dollars over the next decade vastly out way the costs.”
He was, however, very sympathetic to concerns by many of the conservative members of the study group who are convinced that federal support of the expansion is unsustainable in light of the federal government’s looming budget deficits. Wilson views federal deficit spending as an existential threat to the continued survival of the country, “but standing up valiantly against the excess of the federal government does little to protect the state economically disadvantaged citizens.” “It’s a good war” summarized Wilson in his testimony to the committee “but I don’t know that [Medicaid expansion]’s the right battle.”
This month, instead of dashing to a clinic or to the wards every morning to find my patients, I found myself zigzagging through the streets of Boston to halfway houses, racetracks, and even under a bridge to meet patients. For the last 27 years, Boston Health Care for the Homeless Program has provided access to high quality health care to homeless men, women, and children in the greater Boston area. As one of my fourth year rotations, I had the privilege of completing a small corner of my medical training there.
Prior to this rotation, I had limited experience with working with the homeless or transitional population before. At Vanderbilt, I directed a women’s health week clinic where we bussed women from local shelters to our free clinic to receive pap smears and well women care. I was well acquainted with the nightmare of followup for people without stable homes and lives. When a patient had an abnormal result discovered at our clinic, it would take weeks for me to get a hold of the patient by either calling several relatives, driving around to the different shelters, or hanging a flyer near a Narcotics Anonymous meeting room with hopes that a patient would call us back. Furthermore, discovering a pre-cancerous lesion via pap smear at our free event had limited utility. Without health coverage, their access to treatment depended on the generosity of a few incredible Vanderbilt attendings who extracted internal resources to give these women the care they required.
Having completed most of my training in Nashville, Tennessee, I was familiar with the tension of the question, “If you are unable to provide or offer the appropriate care – is it ethical to screen patients for certain diseases?” It is similar to a question well-analyzed in public health, as screening procedures are often valued at the impact of intervention. For example, we do not have excellent cures or treatments for Alzheimer’s Disease. Therefore a screening program would not be valuable to the patient or to society. A similar tension exists in places like Nashville, where many patients do not have coverage to access treatments to diseases. Even public screening for diseases like diabetes or hypertension feels uncomfortable at times for patients without coverage because without access to proper evaluation and consistent care, the impact is minimal, perhaps even negative.
I broached this question to my attending on my first day with Boston Health Care for the Homeless when we saw a patient, “It’s so great that we are able to reach so many homeless people with these screening programs,” I said, “but what do we do if we find something that needs treatment?” The attending gave me a funny look as she replied, “Well, then we treat them.”
In Massachusetts, 98% of the population has health coverage because of an individual mandate. As a provider, working in a place where people are covered is a breath of fresh air or like discovering clean running water. I am so accustomed to bracing myself every time I realize a patient of mine requires something he or she cannot afford. While my colleagues and I have learned to be flexible and creative in acquiring care for uninsured patients, it’s exhausting. This exhaustion is reflected in the burnout that we sometimes see in our upper levels and attendings.
Boston Health Care for the Homeless also has enormous support such as housing and social services. These services walk hand-in-hand with health care. Together, this program is able to provide excellent care to the unlikeliest of populations.
Enrollment on October 1 is essential. I am running a race to raise money for this breath of fresh air. Support me in my effort here!
“A lie unchallenged becomes the truth” was the first thought that came to mind after watching a TV commercial depicting a “Creepy Uncle Sam” perform a pelvic exam on a screaming young woman in a desperate and highly offensive ploy to discourage young people from enrolling in “Obamacare” whose enrollment officially begins in less than a week.
The conservative group, Generation Opportunity, spearheaded by its 28 year old president, Evan Feinberg, is responsible for the offensive ad. The Affordable Care Act represents an historical opportunity to provide insurance for all Americans for the first time in 70 years. FDR couldn’t get it done, neither could President Clinton but both former presidents should receive an “A” for trying. It is quite obvious that the political wrangling has nothing to do with the healthcare plan itself but the “man” who sponsored it. The hail-Mary maneuvers will not work neither will the political temper tantrums and meltdowns. Obamacare is here to stay and as a physician who took care of Medicaid patients for my entire 27-year medical career, it is humbling to witness the door of healthcare access finally open for all Americans.
I still remember the mean-spirited oncologists in a Louisiana town who would not accept women with cancer as patients because they were either uninsured or had Medicaid. Or the colleagues who booted a pregnant woman from their practice although she was 37 weeks because she turned 19 and was no longer eligible under her mother’s insurance plan. Or the mental health patients who could neither receive psychiatric care or medication because they were uninsured. Hopefully, those days are over. Here are some facts about “Obamacare”:
• Pregnancy is no longer considered a pre-existing condition
• Preventive care such as mammograms and Pap smears do not require co-pays
• Young adults remain on their parents insurance plans until age 26
• Seniors will receive rebates for prescriptions
• The uninsured will receive private insurance and 6 out of 10 people will pay less than $100 per month for premiums which is less than a cell phone bill
• There will be subsidies and tax credits for small businesses
Need more information? Check out the website healthcare.gov that not only explains the benefits of Obamacare but also allows one to sign up for insurance beginning October 1st.
The American people don’t need fear-based misinformation. They need political leaders that are willing to place patients over politics.
All major movements start with a groundswell. I can confidently and enthusiastically report that a groundswell is afoot in the field of Lifestyle Medicine. Defined formally, Lifestyle Medicine is the application of environmental, behavioral, medical and motivational principles to the management of lifestyle-related health problems in a clinical setting. Basically, this is how clinicians work in tandem with their patients in a joint partnership to change health behaviors and embrace healthy living. The ultimate goal is to empower patients as arbiters of their own health care with the tools, know-how, and motivation to keep themselves out of the acute medical setting and maximize their vitality. Just in this last month, I have been a part of three events that show the emergence of Lifestyle Medicine as not only an interest, but an eventual pillar of standard medical education. I enthusiastically recount and reflect on these experiences with you…
Earlier this month I had the privilege of representing the voice of medical students nationwide at a Lifestyle Medicine Think Tank held at the beautiful and forward thinking University of South Carolina School of Medicine in Greenville. The goal of this 2-day brainstorming session was to discuss and develop strategies for integrating the fundamental elements of Lifestyle Medicine into the standard preclinical medical education. But this was not simply a powwow with the zealots marching to the beat of the same drum. Rather, it was a meeting of both the believers and the dubious representing all relevant viewpoints and all with skin in the game. The guest list included: deans from different medical schools, respresentatives of the NBME, LCME, AMA, renowned exercise and nutrition scientists, department chairs from various medical specialties, leaders in health policy, and patients themselves. Together, we identified the opportunities, but also the major hurdles and barriers to curriculum change. Despite seemingly insurmountable odds and complexities from all different angles, we successfully identified five avenues to pursue moving forward. It was not necessarily the outcome of the meeting itself that was the major success—it is the fact that such a meeting with such diverse stakeholders took place that should be celebrated. Acknowledgement of current shortcomings is the first step towards change.
Then, two days after returning to Stanford, we hosted nearly 120 medical students for an evening showing of Escape Fire. The screening was followed by an outstanding panel of Stanford physicians who are addressing many of the themes in the film and creating their own escape fires in their practices. The scene was lively with dozens of first and second year students passionately discussing the film and sharing their thoughts, surprises, and hopefulness. For many, it was an escape from the day-to-day grind of preclinical memorization and a reconnection with the idealisms and aspirations that drew them to medical school originally. It helped to trigger a renewed sense of purpose and recommitment to a cause larger than their own career development. Numerous emails and discussions ensued, and as I write this I am waiting to attend a meeting to discuss how we as students can organize to address some of these systemic issues in medical practice.
And finally, just this past Friday marked the culmination of Docs Run 2.0—90+ students, residents, and attending physicians teamed up to run the Palo Alto Moonlight Run as part of DFA’s larger Race for Coverage initiative. For those have not heard about Docs Run at Stanford, it is a fundraising effort on behalf of DFA and our Cardinal Free Clinics at Stanford that culminates in group participation in a local run, allowing us to simultaneously support preventive health care on a personal, community, and national level. For more information, check out this year’s overview and FAQ sheet. As a team we raised nearly $8,000. The deans came out to run with us and we even managed to pull some weary residents out for some Friday night exercise. And most importantly, we had an absolute blast getting out there in the community, being active, and being part of a cause larger than ourselves. We look forward to continuing this tradition here at Stanford and hope that others will replicate this model around the country.
I think this picture tells the story:
And with that, I give an enthusiastic cheer to Lifestyle Medicine and the future of health care in America!
On Sept 17, 2013, I joined the growing ranks of physicians who have gotten a message they hoped never to receive: “There has been a mass shooting in the area. Prepare to receive casualties.” That morning, a gunman was indiscriminately mowing down people at the US Navy Yard. Within an hour my hospital had geared up to provide both medical and supportive care, answer calls from those seeking to know the identity of victims, and coordinate other services with the rest of the hospitals in the city. In the end, we provided care to only one bereaved family and treated a few minor injuries. Still, the experience drove home the point that medical services are essential to the sense of justice and safety of an entire community. Knowing that physicians and hospitals are there for emergencies contributes immeasurably to the wellbeing of a community as a whole.
Although on September 17, I was proud that no survivor who came to my hospital would have been turned away, on Sept 18, 2013, it was back to business as usual. In the ordinary course of events, medical care in the US is distributed too much based upon what people can afford rather than upon what they or the community actually need. In an emergency, people are treated without regard to their resources, but as soon as the dust settles, only those who have been accepted into the tent of the insured have their needs recognized. Others are left literally out in the cold, or driven into bankruptcy and abject poverty, merely from the misfortune of being ill or injured. The process of healing social rifts, from the effects of atrocity to the more subtle corrosion of poverty and chronic disease, requires the availability of medical care to all.
The days following the shooting drove home other lessons. As more information about the gunman emerged, we learned that he had a history not just of mental illness, and violence, but of prior gun violence. He had apparently recently rented an assault weapon and may have tried to buy a handgun. In the end, he passed a federal background check and lawfully purchased a shotgun. Perhaps because he did not have an assault rifle, the death toll was much less than it might have been. But my religious tradition teaches us that whoever saves single life, it is as if he had saved a whole world. The twelve victims and the gunman himself were each a world lost, lost in a sea of inadequate gun regulations, NRA obstructionism, and a society that puts the right to have a weapon before almost any other right of citizenship.
As a physician, and particularly as a psychiatrist, I am also acutely aware that the tragedy of mass shootings is overshadowed by the daily tragedies of gun murders, accidental and suicidal gunshot wounds and deaths. As a political activist I am continually amazed that the issue of controlling health care costs has been ruthlessly divorced from the issue of controlling the violence, especially gun violence, that drives patients to our hospitals, operating rooms, rehabilitation facilities and morgues at rates unheard of in any other civilized society.
Whatever meaning we choose to derive from this terrible event, it is my belief that all physicians have an obligation to use our medical standing to highlight the tragedy posed by unregulated gun access, and by implication, the drain on medical resources that these completely unnecessary injuries represent.
In my role as Director of Community Health and Service Learning at the University of Chicago’s Pritzker School of Medicine, I helped facilitate a discussion for first year medical students about the ethics of student run free clinics. This got me thinking about their future.
Student run free clinics are society’s stop-gap measure for the uninsured, a place for those without the means to see a doctor to connect with a physician via the intermediary of a student.
Providing acceptable-quality care to the patients who receive their care through student run free clinics will include providing information on how to sign up for health insurance through the exchanges. Ethical care will be connecting patients to the medical homes they need.
What will happen to student run free clinics when there are no more uninsured? The impoverished uninsured may be those most likely to use the clinics now, and those most likely to be covered by Medicaid’s expansion in the states where Medicaid is expanding in the future. Is it fair for people who could be connected to a medical home, to instead be seen in a student clinic with a rotating cast of provider-learners? Ethical practices would need to have volunteers signing up eligible patients for health insurance through Medicaid or the exchanges.
The people who would still be seen in free clinics would be impoverished undocumented immigrants, who aren’t covered by Medicaid expansion and would be unable to afford the premiums themselves. And the healthy working uninsured, who make too much money to qualify for Medicaid, and consider themselves too healthy to make the cost of health insurance worthwhile. Would student-run free clinics turn into sites where the Immigration and Naturalization Service could go to identify the undocumented immigrants, one stop shopping to find the undocumented uninsured?
There are many unknowns with unpredictable consequences as health care reform unfolds. That’s what makes it exciting, and what makes it scary. How will our immigration system intersect with our health care system? How will our patients be funneled to access the best care possible for them?
Time will tell—and soon!
The policymakers we have tasked with improving our healthcare system mean well but have limited optics. I don’t blame them. Capitol Hill is a long way from the hospital bedside. Patients and their caregivers are much better positioned to see routine opportunities for improving the value of our healthcare system. That is why we want to help the people who spend their time inside the walls of the American healthcare system amplify their voice.
Do you have a story about a time a medical bill was higher than you expected it to be? Or a time you wanted to find out what a test or treatment would cost and struggled to find the answer? How about a time that you figured out a way to actually deliver or receive better care at a lower cost? We want to hear from students, professors, patients, nurses, teenagers, octagenarians—anyone with a real story from the frontlines.
For the last three years, more than 300 Americans from all over the nation have submitted stories to Costs of Care’s annual essay contest. To date, these stories have helped drive a productive public discussion about the role of clinicians in healthcare spending and the challenges providers face in making care affordable. The stories have been featured in almost every major media outlet, including National Public Radio, ABC Television, and the New York Times. They have also helped policymakers improve their optics. The Institute of Medicine used the essay contest submissions as case studies for an influential report. The Massachusetts State House used the stories for an oversight hearing on medical debt.
Today Costs of Care is building on this momentum with a new essay contest that will be chaired by four leaders with a track record for transformative change: Andy Grove (the former Intel CEO who is credited with driving the growth phase of the Silicon Valley), Maureen Bisognano (a nurse who became president of the world-famous Institute for Healthcare Improvement), David Goldhill (a television executive whose personal experience with the healthcare system led a solutions-focused bestseller praised by conservatives and progressives alike), and Steven Brill (a journalist whose recent expose on medical bills motivated Time magazine to dedicate their entire feature section to a single story by a single author for the first time in their 90 year history).
Help us build a telescope between well-meaning policymakers and well-meaning caregivers. Nothing is more powerful than a good story when it comes to motivating change. The best submissions are short, informal, and conversational. Entries are due by December 1st, 2013, and thanks to our partner sponsors (the Association of American Medical Colleges and Harvard Pilgrim Healthcare), we have $4000 to award to the cream of the crop. We’re eager to hear from you: costsofcare.org/essay