Saturday was a short day in the office. I came in to handle some paperwork and to see a few patients whom I couldn't manage to work in over the course of a busy week. It was an ordinary day with a typical, ordinary selection of patients....which is to say, that almost every one came with a story which cried out about how we desperately need change in our health care system.
The first item on my plate was a patient who called to say that the asthma medication he had been on for years and which had allowed him to control his symptoms and stay out of the hospital was no longer covered by his insurance.
I explained to him that there were likely alternatives that would probably work as well and proceeded to compose an email to his pharmacist, outlining the possibilities I wanted him to explore.
My patients are gathered in the waiting room of my office on December 31, 2008 to discuss health care. A less than ten minute edited video of this discussion can be seen here.
From my perspective, the pressure from health care financing sources, be they public or private, to encourage doctors and patients to find equally effective treatment modalities at a lower cost is not wrong. I often appreciate this push. Particularly in an environment where drug companies and medical technology companies are pushing their expensive new treatments or diagnostics as the only way to go, a little pushback can help a busy provider make more appropriate decisions.
What is wrong is when the pushback comes because insurance company "alpha" had made a deal with drug company "beta" that makes drug "A" suddenly "preferred" and drug "B" suddenly "non-formulary" while another insurance company has struck a deal with another drug company to do just the opposite! This wastes my time and leads to patient confusion and non-compliance while serving little or no social benefit. Multiply these arbitrary rules by the three pages of different insurance companies with which I must be involved and you can imagine the daily waste this produces.
My first patient, M.R., walked in, largely recovered after his recent hernia surgery, but concerned about the findings of his pre-operative exam when he was noted to have aortic stenosis, a type of heart condition which makes control of his elevated blood pressure even more important. His major concern, however, was to see if I could provide him with free samples of the blood pressure medication, the dose of which had been increased by his cardiologist. His insurance company, like most, only allows him refills once monthly, and with the increased dose he was going to run out earlier than expected.
The rule that patients can only get a month’s worth of medication at their local pharmacy (a three month supply is generally allowed if patients use a mail order service) has its origin in the fact that in our mobile society patients may switch employers, and hence health insurers, fairly often and is tied also to the fact that there are so many uninsured in our country. It is a logical business decision. If an "insured" this month may be an "uninsured" or an insured of a different company the next month, then why allow him to have two months of therapy? Similarly, why take the chance that an insured might pass on medication to an uninsured friend or relative? Of course this would not be a meaningful issue if all health care were covered under a single payer financing system, but that is not the system I deal with.
B.R. slipped in briefly afterwords so I could remove sutures that had been placed a week earlier in the emergency room. While I snipped and pulled them out of the well-healed wound we discussed his gouty arthritis and I reviewed the proper use of his medications. It is good, indeed essential, that there are emergency rooms when we need them, but as he left I considered how much more efficient and cost effective it would be if we had a health care system which would have made it easier for B.S. to have had his stitches placed by his primary care doctor who could manage his gout at the same time.
Next came, G.C., a longstanding patient whom I hadn't seen for three or more years. Her blood pressure was way up. Why? "I haven't had insurance, and times are hard." She had been separated from her husband, an alcoholic and methamphetamine addict, but now they were back together, he was clean and sober and employed with insurance. We joked in a bitter way about how unfair it seemed that she and her husband should not have had health coverage at a time when they needed it most. Understanding the nature of one aspect of the waste generated by the private health insurance industry she sardonically remarked, "My husband works for The cable company. They’ve got a pile of different cable 'plans' to choose from. I guess it works the same way with health insurance. The companies spend a lot of our money figuring out "plans" that can extract the most money from each one of us."
D.E., my next patient, came to update much-delayed health care maintenance evaluations. A lovely, gentle man, this 59 year old handyman carries so-called consumer-directed health insurance because this type of high deductible high co-payment insurance is all he felt he could afford. Unfortunately, the up front costs to him had delayed him from coming to see me. As he confided that he was at a loss, not sure what he was going for health coverage in the future after having this month received a notice that his family's insurance cost was set to rise by $400 a month, I realized that today’s visit was a way of getting as much done as possible before he would take a chance without insurance.
His predicament reveals the fallacy in the notion that making insurance "available" will somehow lead to people being insured. Instead, it results in patients not buying the medications they need, delaying or avoiding preventive health care, and ultimately, as I suspect D.D. will decide, risking going without insurance at all. A need for even a minor surgery or an illness requiring a few days hospitalization could be all that is needed push D.D. into bankruptcy, joining the 50% of all American bankruptcies caused by health care expenses.
In the interest of completeness, I'll note that the next two patients, K.N., a 62 year old man with severe heart and kidney failure as a result of a viral infection, whose health coverage comes from the county's Medicaid HMO, and B.E., who has a private employer-based H.M.O. insurance had no current problems with respect to their health coverage.
I then taught L.Q., a twenty one year old student here for the third time this week for treatment of an abscess, how to care for her wound herself. It probably would have been better to have scheduled one more visit, but as she has no health coverage, even with the deep discounts I had provided for my services, the costs of treating this infection have been adding up.
In considering her care, and the way in which I’ve offered her a discount, I think about the health insurance crisis in this country from my perspective. I serve a wide variety of patients, from all ethnic and economic circumstances, and with many different sources of payment for their care, in my practice. From some I feel well-paid, from some I feel less well paid. Although I try not to let this happen, there are times where this disparity has felt oppressive to me and where I’ve felt it could affect my judgment or my enthusiasm in providing the care a patient needs. Many of my colleagues wrestle with the same issue, some resolving the problem by going outside the usual health care system or restricting their practices to patients or insurers which pay the best; others accepting the reality that even a "poor-payer" pays more than the marginal cost of adding on an extra patient. I have found it difficult to place any limits on my practice based upon ability to pay but find myself longing for a unified system where such disparities would disappear.
E.R. came next, thinking he needed a physical, a result of having paid on his own for a "comprehensive health screening" which had identified a number of problems for which he was advised to follow up with his physician. His insurance plan is actually quite adequate, and the health screening he had paid for included tests which were not only unnecessary, but which are considered by The United States Preventive Health Services Taskforce to be counterproductive, because of their documented uselessness or tendency to lead to bad medical care. As I discussed with him the results of his screening tests and reviewed appropriate health care maintenance guidelines, I mused to myself about how good it would be to have a health care system guided by research into what really works best at lowest cost rather than a system which is pushed primarily by a focus on how to make the most money....
Finally, came M.N., a new patient, a 31 year old research biologist with acne. I enjoyed the visit. We talked about the pathophysiology of acne, the pluses and minuses of the different drugs, and about her work. I decided not to address the fact that her insurance might not allow a dermatology referral because her condition, at her age, was considered cosmetic. I wanted to enjoy just practicing medicine for a moment.
http://www.dailykos.com/story/2009/2/8/191145/0843/17/694588
