American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, August 6, 2010

The uninsured

The following post appeared in March 2009 on Musings of a Distractible Mind.

Have we made any progress?

There's lots of discussion among politicians and "experts" on TV about the uninsured. The number is growing, and the push among some is to make sure there is "universal" coverage (which I assume covers people in the Horsehead Nebula and Andromeda Galaxy). The idea that some people would have no coverage for health problems frankly baffles people from other countries. How could we as a "civilized" country allow people to be without coverage?

Andromeda Galaxy image by NASA/JPL-CaltechI'm not going there. The social responsibility crowd can fight it out with the social Darwinists. I'll wait for the fight to be on pay-per-view as the Mega-Healthcare Social Responsibility Smack-Down. It's probably the sanest way to solve the problem.

No, for me the issue of the uninsured is very different. We talked about it this morning in our office management meeting. How do we deal with the ever increasing number of people coming in without insurance? The issue is very complex and really gives us physicians significant inner conflict.

On one side, we are wanting to do whatever we can for the health of these people. Many of them have been our patients for a long time, and we have taken care of many generations, neighbors, friends, and coworkers. Some have been huge advocates, sending anyone who asks to our office. As a physician, I don't really care if I make lots of money off of these people. In truth, because we don't have to deal with insurance billing, they actually cost us less than insured patients. If I could, I would just charge them enough to remind them they are getting a service from me that does take my time, training and skill to give.

But it's not that simple. Even if I do discount my uninsured to minimal levels, the real problem for me comes when they need labs done, tests run, visits to consultants, or hospitalization. My charge is nothing compared to the amount they can accrue in these other venues. This ties my hands as to what I can do for them. They don't get the care they need because it is too expensive.

One such patient that visited our office recently had a catastrophic eye problem that needed immediate attention. If immediate help was not given, blindness was likely. Despite strong warnings of risk and a direct call to ophthalmology, the patient refused to get the care required to save their vision. Most cases aren't this extreme, but the likelihood of us running labs or referring for consults is much lower in the uninsured. Another problem that happens is that money gets between us and our patients. We see them, do what we can to discount their bill, and try to collect a payment. Some don't have full payment on them at the time of the visit, while others can barely afford it at all. We bill them the balance; some pay in full, but most pay either in part or not at all. The next time they come to the office we not only have to charge them for the care they are getting today, but also for past charges.

This is when one of my billing staff comes to me with the "what do you want to do?" question regarding them. Most of these are people I know. I don't think of them as customers, I think of their kids and parents. I think about the medical struggles they have faced or the tragedies they have endured. I like my patients. Playing "hardball" is not that easy when you have an emotional attachment to your "customer."

The issue of the uninsured will be on the lips of many pundits. Some will say "they pay for cable TV, so why can't they pay for medical care?" In some ways, they are right. I have worked hard for my degree and work very hard every day for my patients. I do deserve to be paid. But my job is to take care of people. I want them to view me as a person, not a commodity. The Hippocratic Oath says, "First, do no harm." Not doing harm is getting harder and harder these days.

It probably would be less complicated if they were from Andromeda.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

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Blogger American Journal of Medicine said...

Thoughtful article. The issues surrounding who's insured, who isn't, the extent of coverage, the affordability of coverage, and how it relates to patient care are indeed complicated.

I know a young couple who is expecting their second child. Soon after they learned they were pregnant, the mother-to-be learned she would be laid off and lose her insurance coverage and that of their 6-year-old before the end of the year. The father works for an employer who doesn't offer family coverage. Coverage for the expectant mother and the youngster is $900/month.

This young couple makes too much for the state's Medicaid program, but $900 is NOT affordable. It is more than they pay in rent.

While conservatives in Congress and the media criticize "Obamacare," few offer solutions for couples like this one.

August 6, 2010 at 2:40 PM  
Blogger kg said...

AJM says it well. Hard choices are made every day. The fuss about cable TV is a smoke screen for the real problem. Health problems cost much more than cable. Cable is a small predictable monthly expense that can be canceled easily. Running up medical bills leads to ravenous bill collectors and financial ruin. Cable is a fun distraction. Medical problems are fearsome. People with little money tend to spend what they have when they get it because who knows if they'll ever have any more.
Dr.s can be nice, supportive and relieve discomfort, but generally medical treatments are uncomfortable. And maybe the problem will go away if one waits long enough...

I appreciate your distress Dr. Robb, and I do try to deal with health issues appropriately, and pay bills on time, but I have not always been a "pre-existing" condition, fighting insurance company, and trying to keep head above water and live to fight another day. I am now.

We were better off when few or no people had health insurance and we just paid cash or made arrangement to pay.

August 6, 2010 at 4:26 PM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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