On many levels, I hate to venture into anecdote territory when it comes to health care reform. I don't think it informs the debate in a helpful manner, and yet, it seems to be one of the two major arms of the conservative campaign against health care reform. First, they argue, look how awful it is everywhere else and how wonderful we have it here in America with THE Best Health Care System in the World (TM) and second, they find even medicare, Social Security and unemployment benefits ideological anathema.
I can't do anything about the second one, but I do have something to say about the first.
I was prompted to write this because, yet again, a talking head on TV spouted out a fallacious "fact" about health care in the UK. Maria Bartaroma alleged that England's NHS won't pay for a certain chemotherapy drug. A full minute on the interweb proved this false. Surprise!
But the real reason is because, people ask me, as a doctor, why I am in favor of health care reform. Because I, we, see the inhumanity of our system on an ongoing basis, some of us continuously, some of us intermittently.
I practice intensive care medicine in a very nice suburb. I routinely see patients who, as conservatives famously point out, can "get taken care of in any emergency room." They can't afford to see a neurologist to have their seizure medicines adjusted and so they develop status epilepticus, they can't afford to buy their blood pressure medicines and so develop hypertensive crises, they can't afford their insulin and so come in in diabetic ketoacidosis, they don't have a primary care doctor to see about their ear infection or urinary infection and so on. Mental health access and suicide attempts are a category all their own.
My most recent heart breaker, however was a recent patient who came into our ER (lucky bastard!) and then my ICU for respiratory failure due to his lung cancer invading his lungs and airways and metastasizing around his body. He'd been coughing for more than half a year, coughing up blood for months and finally came to us in extremus. He was a middle aged professional who'd lost his job a year prior and no longer had insurance, so did not seek help until he was sick enough to need taken care of in an emergency room.
And this is not isolated, though so memorable to me because he was about my age, and reminded me of my brother, an engineer who was between jobs and without insurance. A family illness nearly bankrupted him. My patent's fear of the financial consequences of seeking help were absolutely on the mark. Even finding his cancer earlier would have likely broken him financially. Could he get a "do over," I'm sure he would choose differently, but his hope that he'd get by won out over his growing cancer until too late.
I see these really sad cases on a regular basis. I emailed a few colleagues for some stories as well. Here are a few.
My most recent and dramatic horror story is that of a 22 year old female, employed and uninsured, who came to the office last November with bilateral conjunctivitis, presumably viral, but didn't know if she could go to work or not. I reassured her and, my hand on the doorknob, she asked if I would examine her abdomen, which had been increasing in girth inexplicably for the past 6 months. Monogamous with her partner, on OCPs, and menstruating regularly- friends and family thought for sure she was pregnant. I palpated a huge tumor that was an ovarian malignancy. Getting her scans that day (she was tachycardic due to this huge mass compression on her vasculature) was ridiculous- trying to negotiate with radiology about pelvic vs abdominal u/s for starters- she would get a discount if she paid out of pocket that same day so we had to pick one study- i went for the pelvic and sure enough there was the tumor. Then i wanted her admitted that day out of concern for hemodynamic instability. The gyn-onc service at the University hospital said she had to go through the ER- apparently you can't direct admit someone without insurance. She lingered in the ER, where they repeated the imaging, for 24 hours. Finally got a bed. Was suppose to follow up with me. . . never did. didn't qualify for Medicaid. According to the oncologist in town who managed her in follow up, her prognosis was good with chemo (after removal of a small watermelon sized tumor) but all of his care was charity. unreimburseable.
pathetic, no?
I am taking care of a patient, who is a vet and has veteran's insurance. His condition is not covered by his insurance as they are not service related. He is in hospital for 4 weeks now. He sustained a stroke this time. Unfortunately this poor guy has no place to go, not even rehab. Social workers in the hospital has been working day and night to figure out what to do----- no answer. Family said that they are not able to take care of him.
Case #2 : 26 yr old female with DM-1, admitted with DKA. Pt stopped meds as she can't afford to buy. She has hypertriglyceridemia which caused severe pancreatitis. This young lady is in hospital, in ICU. As she doesn't have insurance, she will probably be back for readmission, if she goes home this time.
These are current cases.
I had another case last month, where a 49 yr old female who had a diagnosis of melanoma, lost her insurance and lost follow-up. Four yrs after, last month, she was admitted with brain mass, found to have metastatic melanoma.
I have seen multiple cases like this. I work in Las Vegas. There are many patients who do not have insurance or do not have adequate insurance. Often we treat them in a hospital then they go home and do not come back until they are very sick.
I work for a small community health center in Montana and see a lot of rural health care horror stories.
One woman from a about an hour outside of town came in with a large (8cm) squamous cell cancer that had eaten away the better part of her nose. She had had it for years but didn't have any insurance and never sought care. she found out we have a sliding fee scale clinic and that she could be seen for as little as 12$. She was seen, biopsied and treated with radiation, costing thousands which the hospital helped to write off - however this would have been a 50$ shave biopsy 4-5 years ago. Also she is now horribly disfigured.
Ms. "A" was a 52 y/o AA female who had suffered a hemorrhagic CVA about two years earlier. She recovered nicely, but it took nearly six months to finally titrate three separate antihypertensive medications to the point where her BP was well controlled without any adverse effects. She did well for the next two years, until I received a frantic call from her stating that the pharmacy would not refill her medication because the insurance company would not cover it. One of her meds was prescribed at higher than the recommended dose, but it was necessary, there were no adverse reactions, and the company had paid for it for nearly two years. It only became "refused" when they began using a pharmacy benefits management company.
I assumed it was just an error, and called the pharmacy, who referred me to the insurance company, who referred me to the pharmacy benefits management company, who told me that they refused to cover the excess dose, but that I could fill out their form and fax it to them with a letter of explanation and they would act on the appeal. During the next two weeks, I spent hours on the telephone, writing letters, filling forms . . . all to no avail. By that time, I was running out of the samples I was giving her, and could think of nothing else to do, so I called her and asked if she would like me to represent her legally. When she agreed, I faxed a letter to the pharmacy benefits management company stating that since they agreed to cover the medication, but not the dose, I considered it to be a "therapeutic decision," rather than a "coverage decision," and would thus be held liable if my patient had another CVA. Within four hours of my sending the fax as an attorney, my patient was covered!
That was the case that caused me to transition into the full time practice of Health Care Law. I decided I could do more good for people in my current capacity than I could as a physician; sad, isn’t it?
"John is a 34 year old American-born man with diabetes diagnosed at age 16 and severe hypertension since his early 20s requiring several blood pressure meds he cannot afford due to a lack of insurance. John works part-time in construction and attends community college in the afternoons/evenings. Neither venue offers him medical insurance. Between his diabetes and hypertension meds, he would need to spend hundreds of dollars out of pocket, money he does not have. On his first inpatient admission, he was complaining of blurry vision, headache, and some shortness of breath. He was in hypertensive urgency with a blood pressure markedly elevated at 225/156 and abnormal kidney function. After controlling his blood pressure and sugar, John was discharged with a supply of his medications to last him two weeks while he applied for Medicaid coverage. However, one month later, while his Medicaid application was still pending and he had run out of meds, John returned with shortness of breath and profound renal failure which would not budge. At the age of 34, he was declared to have end stage renal disease and was started on dialysis. Dialysis patients automatically qualify for "straight Medicaid", a free ticket for essentially unrestricted medical coverage. His medications were now free and thousands of dollars were being spent on his behalf. At age 35, after a year of dialysis and several inpatient admissions, John received a renal transplant! His renal function is now back to normal. In addition to blood pressure and diabetes medications, John must take expensive immunosuppressive agents to prevent rejection of his new kidney. He also has frequent appointments at renal transplant clinic. Had John had access to medical insurance that was not linked to full-time employment, he and the medical establishment would have saved hundreds of thousands of dollars and immeasurable suffering could have been avoided."
There are more, obviously. This just represents a few memorable stories from some friends. My personal opinion is that the work of Remote Access Medical alone, the thousands upon thousands of desperate people they have seen, trump any and all horror stories that conservatives care to trot out. It helps our side that most of their stories are pure fiction, but it doesn't help that our media doesn't seem to know how to use The Google.
Bottom line? You can't scare physicians about rationing and bureaucrats and death panels and all the rest of the dreck. We've all seen far worse here in America, and finally we've (mostly) all had enough, thus explaining why all major physician organizations are on board this time. The AMA, AOA, ACP, AAFP, ACS, ACOG and more can no longer oppose health care reform. It's unconscionable and most of us know it.
If you want more of this, I have an entire section on my blog devoted to
"anecdote-off" items. Have fun.