:: to the teeth ::    thoughts on social justice, medicine, race, hope and beats

"Another world is not only possible, she is on her way.
On a quiet day, I can hear her breathing." :: Arundhati Roy ::

"The most common way people give up their power is by thinking they don't have any." :: Alice Walker ::
Thursday, February 02, 2006  

Clinic Vignettes - February 1, 2006

Yesterday a patient called from an ER. He had been there a few hours already with a cut on his hand and was looking at a long wait and a huge bill. We were open so he abandoned ship, left the ER, and with his hospital bracelet still on, came over to the clinic for stitches. 20 minutes, $40 and 4 stitches later, he was on his way home... it doesn't have to be that complicated.

A pregnant woman showed up at the clinic around 6 weeks gestational age. she was complaining of passing a clot vaginally. no cramping. she was concerned that she was having a miscarriage. she had already scheduled her first prenatal appointment, but it wasn't for 6 more weeks at the local hospital clinic for poor women. noone educated her that she could go there sooner if she had a problem. she was already concerned that the public hospital ER would not treat her well thru bad experiences of friends, neighbors and her husband, so she refused to even consider going there. With an exam and the ultrasound i was able to verify that she still had a viable pregnancy but was at risk of miscarriage. we are watching and waiting this week to see what nature will do.

i've mentioned this previously - Spontaneous miscarriage is one of the most frustrating health policy situations for me as a doctor. pregnant women hope beyond hope for a normal pregnancy and a healthy child. the medical system is geared for maximal cost and reimbursement. uninsured woman have no easy access to urgent care. most private urgent cares charge $150 up front so the ER looks alot more inviting since the bill comes later. Miscarriage early in pregnancy is a natural, often sad, but fairly uncomplicated medical problem that doesn't necessarily need much intervention, and there is NO WAY to medically prevent an early miscarriage. put it all together and you get financial injury compounding emotional distress. it's just not right. can some politician PLEASE take some leadership on this?

ths same woman's husband had already had an ER experience for a badly infected big toe. They removed his toe nail for him. guess how much he was charged. $800.00. blows my mind.

at what point does it become unethical and/or even illegal to charge someone exhorbitant prices for basic medical services? there is a law called the New Mexico Fair Practices Act that supposedly is there to prevent used car salesmen from ripping off unsuspecting customers. It;s about time to see if this law applies to healthcare as well...

these stories just keep on coming. i'm determined to share stories every week now, if nothing else to document the incessant toxicities of our health care system.

today a young women came to my clinic with one year of abdominal pain. she had previously had her appendix cut out at the public hospital for the same pain. turned out that the appendix was normal. (as a medical side note, that doesn't particularly bother me. for a surgeon to be sure that they aren't missing any life threatening surgical conditions, they have to have the flexibility to make some mistakes in the direction of unnecessary surgeries to some small degree. in a statistical and complex world, i'd rather have a surgeon make some mistakes like that than be too stringent and make mistakes that cost people their lives.) given all that, the problem in this case is once again, FINANCIAL. this young woman was given a bill of $50,000. did you catch that? $50,000. for removing an appendix. she is a citizen, but for some loophole she didn't qualify for the public hospital financial assistance so she is now paying this bill for the rest of her life. ain't right. perhaps $5,000. it just ain't right.

andru

posted by andru | 2/02/2006 04:12:00 PM | |


Comments:

Some of the things you speak of in this post are definitely better dealt with in a clinic setting. If these patients choose to recieve care in an EMERGENCY setting, then they should be charged an emergency bill rate. So many times i've asked a patient "did you go to your family doctor?" patient says "no, i don't have insurance" so what? does the patient think the ER is free? The hospital ends up eating the bill, and in turn cannot hire enough nurses, or provide necessary equiptment to provide care.
Kudos to the guy that came to your clinic for stiches!!!!! The public actually needs educated on what is an emergency and what isn't.

# posted by Anonymous jen : 2/07/2006 4:53 PM  

Jen,

thank you. and i agree completely that the public needs to understand what an emergency is.

from my experiences there are a few things missing from your analysis of the problem to ensure a balanced understanding, at least for public hospitals. the hospital might "eat" the bill, but not before taking the patients credit rating down. it is not a benign process for uninsured patients. some states don't allow medical debt to affect your credit rating but New Mexico does.

the second point is that "educating" the public is no easy task. our system is the most complex in the world and it changes every day and with every new receptionist. i can call the same x-ray facility three times and get three different answers to the same question, on the same day. how do you educate the public on that?

the third point, and the most depressing for me, is that there are health policy decision-makers working at levels higher than me and you who know that this is a FLOW problem and CHOOSE not to try to find simpler solutions for already overwhelmed poor people. Our public hospital could open some of their clinics after hours. they could actually have an urgent care (which they don't). they could expand same-day access in their primary care clinics. they receive alot of public money to accomplish these systemic solutions with, but choose to spend the money on building new ICU's and bigger ER's... hmmmm... i wonder where their priorities are?

they choose not to open more clinics because it costs the hospitals less to let everyone come to the ER for care. think about it. in the ER, it doesn't matter how busy it is, the staffing costs are fixed. slow or busy. and the real cost underneathe all those high charges are pretty rediculously low when you explore into it. gauze doesn't cost that much. also, ERs are compensated thru some wierd medicare rules and local/state/federal funds based on how much uncompensated care they do, so they are not as hurt by this as they let on.

yours truly frustrated as well,

andru

# posted by Blogger andru : 2/08/2006 3:17 PM  

Follow Up Information:

the woman did have a miscarriage after all. and it turned out to be really rough. she started bleeding, passing clots, and her husband got concerned so he took her to the ER. of course, the ER cannot do anything for a miscarriage so they reassured her. it didn't work. she went back two more times to the ER because she was getting more crampy pains, more bleeding - she was scared. they finally tried to schedule her for a procedure called a D and C but when she showed up for the appointment, it wasn't scheduled for her. it got dropped somewhere.

during all this time, she was calling my office to get help from us but she never left a message. she finally caught a live person on our end and i wound up seeing her late last night. i did a D and C for her. she had placenta stuck in her cervix and alot of clotting. no signs of infection. after 15 minutes she felt much better and we spent about an hour debriefing her whole experience.

and here we go again... the big bills will start coming.

it's so complex. she was informed. she had access to my clinic but didn't leave messages. she knew the ER cost alot of money. she went there three separate times and had alot of docs and residents sticking their fingers into her cervix with no help. so who is to blame? probably noone.

maybe a better question that we need to start asking is, "how do we make it better?" health care is not shopping, it is not a free market. it is fear, trust, specialized knowledge, life and death, complexity, confusion, science, greed, prejudice, art, miracles, profit, service, history and hope. it doesn't fit into any nice box.

all of us are to blame. all of us, patients and providers, have roles to play. we each can help it get better or crumble even further.

what we cannot have is a system that preys on people's fears, that profits on people's pain and suffering, even inadvertantly, even if our internal intentions are good. objective reality must at some point help us find our way to a system that promotes wellness, that eases fears, that reduces suffering, for EVERYONE. there can be no collateral damage if we are to consider ourselves moral leaders, helpers, servants of the people's health.

andru

# posted by Blogger andru : 2/09/2006 12:32 PM  

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