The Frightening - And Typical - Scenario
Benjamen Brewer, MD, commenting in the 23 July 2008 Wall Street Journal on the effect the current economic problems have on his patients, describes this vignette from his practice:
A patient quit smoking so he could afford gas for the 40 mile commute to work in a packaging plant. He has been living paycheck to paycheck for years and his rent just went up. I was glad that something finally motivated him to stop smoking.
The bad news was that he came to the office with severe pneumonia two days after refusing to let an E.R. doctor admit him to the hospital. My patient was afraid of the expense and all the time he would go without pay from work.
To make matters worse, he didn’t fill the antibiotic prescription he was given either. The $50 co-payment was unaffordable, he said. This is a case when an insurer would have been better off picking up the antibiotic tab to avoid a larger expense. But there’s no easy way for a doctor to override a plan’s co-pay or to let an insurer know its rules are about to make something very expensive happen.
When the patient came to see me, his condition had deteriorated. I persuaded him to let me admit him to the local hospital. He was in such bad shape that he was soon transferred to the ICU of a large medical center. His care will end up costing tens of thousands of dollars.
Commentary
I suspect there are few physicians in clinical practice who could not relate similar stories these days. In addition to its poignancy, however, this episode is also instructive. Patient compliance rarely seems to hinge on a few dollars but our health system operates as a fiscally leveraged system in which huge costs and fees are pragmatically payable only through insurance and other third party payer plans. The loss of a job or a health benefit has consequences beyond a decrease in income or the dollar equivalent of a health benefit. Without insurance, the individual is vulnerable to costs that one can neither control or pay. One result is that financially dependent compliance is remarkably brittle. We should not be surprised that a downturn in the economy has a tremendously magnified negative impact on compliance.