Saturday, October 13, 2012

Patients 11, Insurance but No Insurance

     Mr. X was accompanied by his wife, Mrs. X.  Like many others, they had been my patients at Hawthorne Medical Center--but I hadn't seen them for more than three years.
     "We've been going to Clinics A, B and C," they said.  "But we really haven't had anyone examine us since you.  No one else does physicals."
     Mr. X had blood in his urine--lots of it.  "The toilet is bright red after I go," he said.  "Also, I'm having trouble breathing."
     "I know you'll figure out what's wrong," Mrs. X said, clutching her hands in her lap.
     I asked a lot of questions, did a physical exam, obtained a urine test and two ultrasounds--bladder and renal--and had an answer.  There was a solid mass in Mr. X's left kidney--probably transitional cell carcinoma.
     "Could it be from having worked with asbestos for twelve years?"  he asked.  Years ago a class action lawsuit had been filed without his ever knowing about it, and many employees had been paid off.  "It's too late for me, now," he said.
     There is evidence that renal carcinoma might be related to environmental toxins, including asbestos.  But Mr. X's current problem was even bigger--if that's possible--than having cancer.  How was he going to pay for specialists and treatment?
     Two years ago, at age 57, he had been laid off at work.  He couldn't find another job--"No one wants to hire a man in his late fifties," he told me--especially not in the specialized field he had occupied for twenty-seven years.  He had Cobra for the first year's health insurance, but finally couldn't afford the $1200/month premiums..  His wife hadn't been working, either.  They'd been living off their savings and negotiated a less expensive health insurance plan which promised a lot.
      My billing staff ran a report on his insurance.  It required a $5000 deductible for all services except a physical exam once a year.
     "We don't have that kind of money," his wife told me. "We're out of money.  We've used up our savings--what are we going to do?"
      My office charged him a minimal ultrasound and x-ray tech fee.  His insurance, "Golden Rule," didn't even cover a basic blood test.  So, how was he going to pay for a surgeon, CT scan or chemotherapy?
     After some calls to his insurance company we found out that he has to pay 30% of his hospital costs, should he be admitted.   "We thought we had insurance, but really we have no insurance at all," Mrs. X despaired.   "The agent lied about our coverage," she went on, citing things she was told the plan covered, that weren't..
     I was wondering if Mr. X should wait until January, when Obamacare is supposed to kick in, covering 40 million people just like Mr. X--people who have lost their jobs, run out of money, and can't afford health insurance premiums any longer.  Obama keeps talking about people in the middle, who have no coverage.  It's true--many of my patients don't work and have nothing, but are on Medicaid, which pays 100% of all medical costs.   If Mr. X hadn't worked for twenty-seven years before being laid off, and if he hadn't had any savings, he'd have Medicaid, too--and no worries about how to pay for the next few months of serious care.  I guess his mistake was that he held a skilled job for several decades, and accumulating savings for retirement.
     Mr. X can't wait until January--time is of the essence, with cancers like this.  The tumor, which is now two centimeters, could grow to four or five in a few months without treatment.  It could spread outside the kidney capsule, and become much more complicated to treat.
     "Is it true, what the Republicans say:  they just want to kill old people?"  Mrs. X asked.  "Is that what's in the new healthcare plan?"
     "No," I told her emphatically.  "That is not in the healthcare plan, and it's not what anyone wants.  What you heard is a piece of gossip generated by negative advertising meant to get people to vote a certain way, and it has no basis in truth."
     If Mr. X doesn't have the $250 to see a specialist, or the money for a CT scan or kidney biopsy, what can I do for him?  Long ago,  doctors had private practices, and radiology groups were owned by a few doctors who-- free to act like human beings--valued my referrals.  In those days I'd pick up the phone and describe the patient, who would very likely be seen at no charge by the specialist, who would then arrange for other charitable care.  Most doctors were real people, back then, with the ability and compassion to take cases like this.  We all thought, "There but for the grace of God, go I..."
     These days, there aren't any private doctors I can call.  They're all owned by big business--and it's impossible to talk sense, or charity, to corporations.
     Mr. X went home.  His wife was crying.  They had just told their daughter the news by phone, and Mrs. X said she was upset.  Their son is facing foreclosure.  He's out of work, too.
     Unless you believe in magic, no one thinks that healthcare is going to be available to the 40 million uninsured Americans on January 1st.  But a lot of them need it--because they haven't been able to afford a doctor for years.  People like Mr. and Mrs. X say they've been crossing their fingers and hoping they wouldn't get "anything serious" until age 65, when they'd get Medicare.
     The wheels of my brain have been trying to figure out how to use our system to get Mr. X what he needs.  Maybe I should tell him to go to the Shands emergency room, where they'd have to see him, because of government requirements for hospitals that receive state or federal aid.  But the hospital would probably send him home, because he's not having chest pain, or dying this instant.  Besides, they know he's going to be expensive, and the hospital doesn't want to eat the cost of his care.
     I could see if the "We Care" program is still in operation--doctors used to handle a few patients a year at no charge on this program.  Or:  maybe he's eligible for Medicaid, if he's run out of money.  I told him to apply--but cancer moves a lot faster than bureaucracies like Medicaid.
     "I'm so glad we came here," Mrs. X thanked me.  "If we'd gone to that clinic in Hawthorne, they would have told my husband he has a UTI and given him an antibiotic prescription.  Then we wouldn't know anything."
     In the back of my mind, I'm wondering if the government is going to inform me that I have committed fraud by doing too many tests on Mr. X , or by waiving his co-pay, or by doing ultrasounds--all three of these have been intense areas of interest for government investigators in the process of questioning the people around me--my patients and past employees--in secret.
     I hope I can get Mr. X on the right path before I'm accused of doing too much, or ordering unnecessary tests, or--worst of all--caring enough to take the time to figure out what's really wrong with my patients, not what's quick and easy.


  1. This patient purchased a Golden Rule policy high deductible policy. High deductible policies allow individuals to economically insure against catastrophic health emergencies or serious chronic conditions. It is unlikely that this patient wasn't aware of the major details of his policy. Details are described multiple times during recorded sales calls. After purchasing a policy, a copy of the policy is mailed to the insured. Federal law mandates that major policy details be described on the first page of a policy in a standardized format. At least once a quarter, the insured recieves a summary of coverage. While this patient might be unable to afford your services, it is unlikely he wasn't aware of the policy's limitations.

  2. It's true, many patients "know" the limitations of their insurance coverage, but ask for clarification at the time of a costly emergency because they're hoping something magical will happen, and suddenly they'll be covered for services their high-deductible contract doesn't include. Or they hope the doctor will have mercy on them and not charge, because they're in such a serious situation. But the fact is, American's should have health coverage just as we all have the right to a free education. We need to make a decision as a culture: is a healthy populace as important as an educated one? Most people would say yes. How we're going to pay for basic and emergency servics for everyone is the question. I don't "blame" this patient for making the mistake of purchasing a high-deductible insurance--he figured it was better than no insurance, and it's all he and his wife could afford.