Dr. Malia Reckons

Disheartening moments are too frequently part of my day. A recent Sunday evening I got online to check emails and preview my schedule for the week. It was about 9pm and I was struck by three of the emails waiting for me. After considering them and replying to each, about 20 or 30 minutes later, I was disheartened about the options for health insurance reform discussions.

Each email related to financing of health care and was distinct in character from the other two.

And each was relevant to the current discussions of health insurance reform.

The first email was the most benign. I had seen the patient the day before, on a Saturday morning, for severe rib pain related to a fall a few days earlier. I highly suspected a fractured rib or two. But she needed pain relief more than anything else. A final part of the plan was to get an X-ray of the ribs on Monday to document the problem.

Her email was to report that the pain was doing a bit better and to ask if she can skip the X-ray. She explained how she has a high-deductible plan and would be paying out-of-pocket for the X-ray. Honestly, since she was doing better, the X-ray of the ribs would not be adding much to the plans. So I did not mind her skipping the study at that point.

The second email was different in character. The patient has a family history of early heart disease and uses two medications to treat his high cholesterol. He has traditional insurance with co-payments for appointments and his monthly prescriptions. In October he is scheduled for blood testing and a follow up appointment.

Though he continues with his overnight job, he is no longer working his part-time day job. Finances will be tight for the next few months and he is searching for ways to save money. His email was to report that he is planning to skip his two prescriptions the next few months and wanted to reschedule his October appointment for later so he can save his co-payments. His message closed with:

"I hope you understand for this time ... Please forgive me." 

My heart ached as I thought of him struggling financially so much that he would send me that message. And, professionally, I thought of how the plan to skip his medicines for a few months would potentially increase his risk for long-term heart and vascular disease, or, with high triglycerides, increase his risk of acute pancreatitis.

I replied with some ideas about saving money for his medicines and his care such as invoicing his copay that he can cover later, or checking other pharmacies for cheaper out-of-pocket costs for his medicines, but I have not heard back from him.

The third email that evening was from a young woman who has no insurance. She has some baseline mental health diagnoses which require two prescription medicines daily. She is working hard to improve herself and move forward in a positive way by attending a community college full-time on financial aid loans; plus she is looking for a part-time job.

Since last spring I have had concerns the medicines I am prescribing her are causing problematic side effects. I made adjustments and asked that we follow up more closely. Primum non nocere (First, do no harm) is a primary edict in medicine dating back to ancient Greece, so monitoring prescription medicine side effects is paramount to my job.

This young patient needed her prescriptions updated. Without them she likely could not continue in school. But she has no medical insurance and can not afford another appointment. Actually, she already owes me for the equivalent of three or four prior appointments and has from time-to-time gotten me some extra cash. So she was stuck between a rock and a hard place, and, professionally, I felt the same.

I have known her family for 16 years, have worked closely with her through many hard times and have been there as she worked to improve her health and life. She owes me money and needs medicines which I worry are causing problems. Another appointment would increase her debt, or lead to charity work by me.

No easy answers, but my soul ached. I did what I can for her and offered a plan to work together on these issues. After a few email messages back-and-forth I felt confident she was doing better after the medicine adjustments from the last appointment. She is continuing on her medicines which help her maintain a positive trajectory in life. We are planning an appointment in the next couple months so I can properly assess her. And she will continue doing her best to pay off the amount due for her appointments over time.

Our relationship as patient and doctor has been long and rich -- that richness gives value to what I do and, I hope, nourishes her life. I am not willing to drop out of her life professionally due to her life's current stresses. In the years ahead I look forward to her success and trust these difficulties will be only memories. Yet her struggles, and the need for that email, and her need to balance mental health problems with medications with school and with finances, are painful to see.

And so, late that Sunday evening, just a few hours before another week of patient appointments was to begin, I was disheartened. Patients faced financial challenges with traditional insurance, high-deductible insurance and when having no insurance. As a physician I feel a moral obligation to care for them, a feeling that goes beyond the business of health care. But, in the end, society has made health care a business, and there is only one way to keep the doors open in the American marketplace. I used time to try to help these three patients, but my soul's bruising made me less effective the rest of that evening, and each time I thought of the three of them since then.

What are the answers for financing health care so patients can at least get the treatments they really need and doctors can focus on providing reasonable services?

Those three emails related to only the most basic aspects of care, nothing exotic, and nothing that should not be part of primary care. Is it too much that I, as a family physician, can hope my patients did not struggle with the costs of only the most basic and reasonable services? And why do we as a nation not think that we all would be better off as a society, as a community, if health care financing allowed that?

Until there are real answers, however, I am certain I will continue to be disheartened; often.

--Timothy Malia, MD