Michael, a struggling actor, came to see me at the free clinic yesterday. He had been in a car accident many years ago and has suffered with chronic neck and back pain ever since. He has had physical therapy, chiropractic care and acupuncture, but still he suffers. For 8 years his pain has been under control with a combination of Vicodin, Xanax and Soma prescribed by a chronic pain specialist. This combination allows him to continue to work and to function. But, Michael doesn’t have insurance. The visit to the doctor is $100 a month. His medications (all of them, generic) costs $140 a month. He has finally reached a point where he cannot continue to afford them. He had two Vicodin left when I saw him last night – he had been taking less in order to make his bottle last a while longer, but now he was in severe pain and needing some help.
We don’t carry any of his medications at the free clinic. Our policy is to not carry narcotics. I could refer him to the county hospital pain management program, but that takes about 9 months to get an appointment. In the meantime, Michael will be suffering from extreme pain plus withdrawal and not be able to work or function.
During the same shift, Elizabeth came in. She is a professional dancer and had a fall while rehearsing. Her knee has been in pain for 7 months, limiting her ability to dance, so she has not been able to get any gigs since the fall. She had an x-ray and physical therapy, but needs an MRI to see if there is a tear. We have no ability to order MRI’s at the free clinic. I can refer her to the county orthopedics specialist, but that takes about 12 months before they will send her an appointment.
Ken sees me in my private clinic. He has high blood pressure and high cholesterol. He takes his medications regularly, but has a strong family history of heart disease. He needs routine blood tests to check his cholesterol, his kidney (make sure the medications aren’t causing any problems there) and general chemistries. His deductible with his insurance is so high, that he can’t afford to have his labs done. I have to decide between continuing his medications (for which he pays a reasonable copay not affected by the deductible) and potentially causing harm to his system that I can’t detect because he can’t have the blood work OR I can insist that I cannot prescribe refills unless he gets the labs done, in which he case he will probably just stop his meds.
Meanwhile, in my private practice, I can’t afford to stay in network. I want to see patients for 30 minutes, not for 10. I want to get to know my patients and discuss what they are eating, how much exercise they are doing and what might be bothering them at home or work that could be contributing to ill health. I want to discuss prevention and treatment options. I can’t do that in 10 minutes. Insurance reimbursement is based on a full billing staff and a high volume of patients booked every 10-15 minutes. The amount they pay cannot support a practice that allows for 30-minute visits.
This is our health care system. It is not working for Michael or Elizabeth or Ken. It is not working for my colleagues or me. It is not working for people with insurance (because of huge deductibles an copays) or people without insurance.
We cannot give up on reform.
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