Susan, a patient of mine, called the office requesting treatment over the phone for an ear infection because she could not afford the cost of a visit with her high deductible insurance plan. Increasingly, I find myself in an ethical quandary: although I sympathize with the under-insured, I do not believe good medicine happens over the phone. It is my responsibility to evaluate a symptom before initiating a course of treatment and that is becoming harder to do if patients cannot afford to be seen for evaluation.
Another patient, Bob, returned after three years during which time he had no insurance coverage. His blood pressure and diabetes went untreated and had worsened, increasing his risk for complications and early death.
In the United States, we have approximately forty seven million uninsured.
The dysfunction of our current health care system is a social crisis. The variety of insurance plans, with their complex rules, is confusing to the patients and providers. Frequently, patients have little understanding of their plans. When a service is denied or the co-payments have risen, patients vent their frustrations at my staff.
Ironically, many of these insurers, in an attempt at "quality contro,l" will harass me with letters listing patients who are not up-to-date on recommended screenings or labs. I have simply started responding by pointing out that it is often the high deductible plans they are selling that keep patients from being able to afford these recommendations. To protect myself from the potential for liability, I also document in the charts when cost or poor insurance coverage interferes with the plan of care. This has been occurring with increasing frequency as our economy has crumbled.
The insurance industry is the elephant in the room sitting between my patients and me. They dictate what can be prescribed, what tests are performed, how much time we spend together, even where prescriptions can be filled. I have had many of my patients decline to provide their medical history to me, fearing they could lose their health insurance coverage. Physicians cannot be expected to do their jobs if patients are afraid to tell us their medical history.
I have had patients denied insurance due to mild arthritis observed on a chest x-ray, and minimal cataracts observed by the ophthalmologist, when I had referred for a completely unrelated issue. Patients become quite upset to learn that incidental findings are keeping them from being insured. I am upset to think that a thorough history and medical exam performed as I was taught could lead to patients being denied coverage. Somehow we never covered this in medical school.
Our current system with private pay insurance plans wastes excessive amounts of money on marketing, sales and lobbying while the costs to employers and patients continue to rise. Administrative costs for the private insurers run about thirty percent. Since 2001, the cost of coverage paid by employers and patients has risen approximately seventy eight percent. Since I graduated from medical school, physicians have faced a yearly battle with Medicare to prevent pay cuts. It has been disheartening to say the least.
The current system of health care has led to decreased satisfaction for both patients and providers. I never wanted to be an assembly line doctor. The longer I do this, the more I have come to understand that listening is the most important thing I do as a physician. It is not high tech or dramatic, but to be heard, really heard is critical to healing. Of course, this takes time. Unfortunately, this is not what is valued in a world of managed care.
As I work within an increasingly broken system I continue to write and speak out on the urgent need for health care reform. Indeed, I think it is the most important thing I can do for my patients.
1. Committee on the Consequences of Underinsurance. Care without Coverage. Institute of Medicine. 2002.
2. Scandlen G. Woolhandler S. Do High-deductible Plans Coupled with HSAs Promote Underinsurance ? Family Practice News. July 15, 2008.
3. The Commonwealth Fund. Why not the best? Results from the National Scorecard on United States Health System Performance 2008. July 17 2008.
4. White, B. How Consumer Driven Health Plans will affect you and your Practice. Family Practice Management. March 2006
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