I saw a patient today and looked back at a previous note, which said the following: “stressed out due to insurance.” It didn’t surprise me, and I didn’t find it funny; I see a lot of this. Too much. This kind of thing could be written on a lot of patients’ charts. I suspect the percentage of patients who are “stressed out due to insurance” is fairly high.

My very next patient started was a gentleman who has fairly good insurance who I had not seen for a long time. He was not taking his medications as directed, and when asked why he had not come in recently he replied, “I can’t afford to see you, doc. You’re expensive.”

Expensive? A $20 copay is expensive? Yes, to people who are on multiple medications, seeing multiple doctors, struggling with work, and perhaps not managing their money well, $20 can be a barrier to care. I may complain that the patients have cable TV, smoke, or eat at Taco Bell, but adding a regular $20 charge to an already large medical bill of $100, $200/month, or more is more than some people can stomach. I see a lot of this too.

Finally, I saw a patient who told me about a prescription she had filled at one pharmacy for $6. She went to another pharmacy (for reasons of convenience) to get the medication filled, and the charge was $108. I could see the frustration and anger in her eyes. ”How do I know I am not getting the shaft on other medications?” she lamented. I told her that I see a lot of this.

Then I started considering how many doctors, nurses, and hospital administrators are “stressed out due to insurance,” and I laughed. I think the number of those not stressed out would be far easier to count. In this blog I have recounted the overall cost the insurance situation takes from my own practice, and my own psyche. I can’t do it justice in a single post, it takes a huge toll on those of us in it. The cost is high.

So what is the overall cost of a bad system? Sure, the system itself uses money poorly and dumps buckets of money on things that have no impact on the health of patients. Sure the system encourages doctors to not communicate, not spend time with patients, and to spend more time with the notes than with the patient. But what is the toll of this toll? What is the toll that simply having an insane system that demands huge sums of cash, yet does not give back a product worthy of that cost? What is the toll of people suspicious that they are being gouged at the pharmacy, hospital, or doctor’s office? What is the cost of having a healthcare workforce that goes home more consumed by frustration about the system than by the fact that people are sick and suffering?

Our system is very sick, and the fact that it is so sick makes me sick. It makes a lot of us sick.

I see a lot of that.

PREVIOUSLY by the same author on THCB:

“The Cost of Fear”
“Dear Mr. President”

ROB LAMBERTS is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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86 Responses for “Stressed Out System”

  1. I hope we all have free life insurance from our government.

  2. archon41 says:

    Equivocate all you like, but it is a simple fact that there exist different qualities of care within the range of “the adequate.” Who, for instance, would not prefer a plan which allows one to select one’s own providers to a region specific, network bound HMO? And what sense does it make to lavish on “the poor” private insurance policies with deductibles and copays? What is wrong with adequately funded community health centers, other than grating on your egalitarian sensitivities?

  3. “What is wrong with adequately funded community health centers…”
    The same thing that is wrong with Medicaid. A program specific to the poor, quickly becomes a poor program.
    Also, community centers are basically charity centers, and while it would make the well heeled feel good about themselves, it is demeaning to those forced to use them. The “health care poor” today include a very large portion of what is usually considered middle class.
    It may be very hard for you to understand, but lots of “poor” people are hard working, proud Americans, like the pickup driving constituency that you seem to identify with, but not really know very well.

  4. archon41 says:

    So we’re going to make them feel “equal” by giving them a product they can’t afford to use?
    I went to a community center many years ago, for an ailment I would prefer not to mention. I didn’t feel at all “demeaned.” This discourse is being driven by partisan ideology, not reason.

  5. Nate says:

    “The problem with your approach is that people cannot “shop” for healthcare.”
    Where did this myth come from? 80% of my population doesn’t have anything more involved them some office visits, Rx, and some test or x-rays. All of which can be shopped. Any given year 80% minimum of patients could act like consumers.
    Of the remaining 20% a good portion of that is also shopable. People already shop, they just case their decisions on the wrong parameters. As I sit here watching the Cavs game 3-4 times Cleveland has told me everyone deserves world class care, this is BS and an example of what the problem is. Everyone doesn’t deserve world class cuisine, or automobiles, or housing, etc. People have this perception they should be treated by the top doctor in the top facility while someone else pays the bill. This doesn’t work and can never be sustainable.
    “The money is in Botox, so that’s where the market moves.”
    This is what happens when the government regulates markets. It use to be easy to find a PCP even in small towns, government “fixed” the healthcare problem and now look where we are.
    “This notion that somehow price shopping will lower our costs is rediculous.”
    It is rediculous to think driving a block further down the street to get the generic for $4 instead of $28 at CVS is praticle. It is Rediculous to think going to the urgent care center instead of the ER for your cold would save money. It is Rediculous to think getting your knee scoped at a free standing suregry center instead of Clevland Clinic will save money. Shoping is so rediculous it could never work.
    “A program specific to the poor, quickly becomes a poor program.”
    Doesn’t seem to bother you when the left passes and funds public housing, welfare, education, etc etc etc. Or is healthcare just first up then your going to throw me out of my house and move in a poor family in the name of equality? Next time I hit the strip for a 5 star meal will I be served McDonalds and pay for the 5 star mean that is given to the poor person at McDonalds? If programs for the poor create poor programs I agree lets scrap them all. With all the money we save we could hire the poor to actually do something productive.
    “but lots of “poor” people are hard working, proud Americans,”
    Lots also aren’t nearly as poor as you think they are. Ever been to the Ozarks? Poorest part of America…why does everyone own a fishing boat and have a realitvly new pick up? Just because they tell the tax man they are poor doesn’t mean they really are poor.

  6. Nate says:

    As a payor I would love to do away with assignment of benefits. Also slash CPTs in half, number of them. Let the patient and doctor decide what his service is worth. I’ll pay a flat $x per office visit and don’t care where you go, who you see, or what you pay him. I’ll insure them against an event or illness happening, how they choose to treat it is none of my business.

  7. “Ever been to the Ozarks? Poorest part of America…why does everyone own a fishing boat and have a realitvly new pick up?”
    Nate, I live in St. Louis, so yes. You are confusing the Ozarks with the resort named Lake of the Ozarks. The poor folks in the Ozarks don’t have fishing boats or new trucks. The area is sheer misery and 1/3 of the hungry are children. You can help here:
    http://www.ozarksfoodharvest.org/hunger.html

  8. archon41 says:

    A man needs a pickup.

  9. Peter says:

    “What is wrong with adequately funded community health centers,”
    I don’t think anything is wrong with them, but I’ve never heard of one that’s “adequately funded”. Talk to the states and ask them if even Medicaid is adequately funded. Clinics are ok for simple stuff, and probably could be for cronic disease management, but when someone needs a hospital where do you propose we send “clinic people”? But I don’t wish to fund clinics or the rest of the system with it’s present understanding of “adequate”, because that’s what’s causing costs to rise so quickly, we’re paying too much for “adequate”.

  10. Peter says:

    “It is rediculous to think driving a block further down the street to get the generic for $4 instead of $28 at CVS is praticle. It is Rediculous to think going to the urgent care center instead of the ER for your cold would save money. It is Rediculous to think getting your knee scoped at a free standing suregry center instead of Clevland Clinic will save money.”
    Nate, you misinterpret (exaggerate) my comment, of course the examples you give are good and necessary cost savers, but I was referring to hospital/surgeon care and the expensive stuff where you can’t “shop” or don’t know what you’re shopping for.

  11. Rob Lamberts says:

    Am I missing something? Is there a “rediculous” inside joke here?

  12. archon41 says:

    “we’re paying too much for ‘adequate.’” Chew on that for a while, Dr. Rob. You’re the one in the “transformational change” crosshairs.

  13. Nate says:

    Peter the problem is most people don’t have hospital surgeon care and the current bill does NOTHING to get people to start going to Wal Mart, Urgent Care, or OP centers. In fact as I have said numerous times this bill actually does the opposite, by capping out of pocket and removing lifetime maximums this bill actually reduces the incentive to control cost. Why drive the extra mile when you already hit your OOP max and the insurance carrier is paying 100% of the tab? This is why reform always makes things worse, its written by people with no idea what the actual problem is and how to fix them.
    Why does reform ignore tort reform, Medicare Fraud, and wasteful spending in private insurance? Obama complains about cost but does nothing but make it worse
    Margalit I know my way around the Ozarks and all the boats aren’t reserved for the lakes, its not nearly as poor of a region and the government reports

  14. Barry Carol says:

    There are two distinct aspects to adequacy of coverage. One relates to scope (what’s covered and what isn’t) and one relates to the cost-effectiveness of the care provided.
    .In the case of the poor, they probably can’t afford to pay much if anything in co-pays. Their lives are often chaotic. Some of them move frequently, many lack transportation and, for that and other reasons, often don’t or can’t keep appointments. Therefore, the medical home concept probably won’t work as well as it would for the average middle class person. I think community health centers could work reasonably well for this population and would certainly be a better and more cost-effective alternative to the ER for routine care. If they just showed up when they needed care, they would likely have to wait, but I don’t think that’s too much to ask within reason. I access urgent care centers from time to time myself. If they’re not busy, the wait is short. If they are, it can be quite long. It’s not the end of the world.
    Regarding cost-effectiveness, I think referring doctors can do a better job here. If a generic drug is available, don’t prescribe a brand unless the patient, for some reason, cannot tolerate the generic. If imaging is required, send him to an independent imaging center, not the local community hospital that insurers often have to pay twice as much for. Even Medicare and Medicaid pay higher rates to teaching hospitals to compensate them for their teaching function, research activities, etc. Avoid them if you can but use them for the complex care that they are best at.
    For those in the workforce, I think employers and unions could do a much better job of engaging employees to get them to care about what services cost even when insurers are paying. Rapidly rising medical costs mean less ability to raise wages. Clearly communicate how much the employer is paying on the employees’ behalf for health insurance. These are simple steps and they don’t require legislation. Employers and unions need to step up to help bend the medical cost growth curve. I urge them to do so and soon.

  15. Peter says:

    Nate, there are provisions for Medicaid/Medicare fraud/waste/abuse:
    “Subtitle A—Increased funding to fight waste, fraud, and abuse
    Subtitle B—Enhanced penalties for fraud and abuse
    Subtitle C—Enhanced Program and Provider Protections
    Subtitle D—Access to Information Needed to Prevent Fraud, Waste, and Abuse”
    Here is the text of the (latest I think) bill:
    http://docs.house.gov/rules/health/111_ahcaa.pdf
    It is onerous to sift through with 2000 pages and I think Democrats could have done a much better job at condensing the bill for discussion purposes. But even though it eliminates lifetime caps I don’t think it inhibits insurance companies from steering people to less costly choices. If you can find that in the bill let me know.
    What I don’t like about the bill is it does not appear to do anything for provider cost controls although it does talk about promoting primary care and prevention and wellness.

  16. Barry Carol says:

    To follow up on my prior comment, I think it would be helpful if people were given health insurance cards that would allow them to track their utilization of services. Both public and private insurers could communicate information about utilization vs. others in the population of comparable age and health status. If high cost facilities like ER’s are being frequently used when urgent care centers are available, the difference in cost should be brought to the insured’s attention. The same goes for independent imaging centers vs. community or teaching hospitals and generic vs. brand name drugs. Just knowing that someone is looking at this can affect behavior in a way that cuts costs without compromising the quality of care.

  17. “In the case of the poor, they probably can’t afford to pay much if anything in co-pays. Their lives are often chaotic. Some of them move frequently, many lack transportation and, for that and other reasons, often don’t or can’t keep appointments.”
    I think we are having a problem with the definition of the term “poor”.
    First of all, there are many people who are classified as lower middle class, but are really poor when it comes to health care. A family of 4 making $60,000 is health care poor, and does not fit the profile above.
    Rural poverty is different than urban poverty. Folks are anchored in their communities and often poverty is generational.
    Poverty in many cases is temporary. Young people that are poor today, may very well ascend to middle class income later in life. Middle aged people who have adequate means today, will be poor when they grow old.
    With the economy being what it is, the ranks of the health care poor will be swelling in coming years.
    If we want to provide a good solution, we must understand that fewer and fewer will be having discretionary income in the coming years. There is a bigger monster at play here and health care accessibility is being affected by it. Whatever design we come up with better be scalable to accommodate the casualties of financial capitalism (replacing industrial capitalism in this country), global economies and a general decline in standard of living.
    If the world is going to become flat then we will be lowered to the common ground as others are lifted to it.
    Of course the alternative would be to grab the bull by the horns and recognize that there is no imperative to throw away hundreds of years of hard work and sacrifice, but I’m not holding my breath.

  18. Barry Carol says:

    Margalit – In my comment referring to the poor, I was thinking primarily of the Medicaid eligible population, especially those who live in the major cities. With all due respect, I don’t consider a $60K income for a family of 4 in many parts of the country as “healthcare poor” to the extent that a $15 or $20 co-pay should be an impediment to care. As I’m sure you know, the cost of living, especially for housing, is a lot lower in St. Louis, Cincinnati and Pittsburgh and many other places than in NYC, SF or Boston. Housing costs are much lower still in most rural areas. That’s the big item in most family budgets.
    Moreover, as Nate says, in any given year, most people don’t need much care. Sure, big ticket events like heart surgery, hip replacement, cancer treatment, etc. are frightfully expensive which few people could afford without insurance. But routine primary care, well child visits, immunizations, etc. are not beyond the reach of most of the insured population even if they have to make a modest co-payment.

  19. Barry,
    It’s true that $60,000 for a family of four is not considered poor in certain areas, but it is in others. The official definition of poverty is inadequate and it is masking the true magnitude of the problem. According to NCCP, almost 40% of all American children live in households below twice the poverty level and as many as 20% of younger children live below poverty levels. http://www.nccp.org/faq.html#question5
    This is not a small problem to be resolved by a bunch of community clinics. Something is fundamentally wrong when the very few rich keep getting massively richer and everybody else keeps getting poorer. It is not a sustainable model for freedom and democracy, and not even for healthy capitalism. Industrial capitalism made this country what it is because, to various degrees, everybody was moving ahead. We are now leaving most of the country behind. I think the results can be easily extrapolated from history.

  20. archon41 says:

    How true. Karl predicted all this would come to pass, and we are paying the price for not listening to him. Now, that Hugo fellow has the right idea.
    This blog really needs a soundtrack. The East is Red, maybe.

  21. Barry Carol says:

    Margalit – We could probably go around and around on this for a long time. Poverty statistics are, presumably, based on IRS data. As Nate says and as I and others have said before, the underground economy is all around us. I see it everywhere from the employees of the landscaping service that takes care of my yard to the waiters and waitresses in the restaurants I patronize, to contractors that occasionally do work on my house to maids and nannies, personal trainers, doctors, lawyers, and many others. Before welfare reform in 1995, everyone knew that lots of welfare recipients were working off the books while collecting benefits. Now, in the midst of the worst economic downturn, the welfare rolls nationally are less than half of what they were just prior to reform during a much stronger economy. Yet, we don’t hear of people dying of starvation now or then though food banks are admittedly busier these days.
    As for the richest among us, much of their income comes from interest, dividends and capital gains which can be extremely volatile from one year to the next. Due to people selling businesses, farms or even expensive homes, some have extremely large incomes one year and a much more modest income in subsequent years.
    While there is no question that good paying job opportunities have declined in manufacturing and construction partly for cyclical and partly for secular reasons, the long term shift in the economy from an industrial base to a knowledge and information base means more people need a college education today to thrive in the economy that we have now.
    The bottom line is that I am deeply distrustful of IRS income distribution statistics and think it is unfortunate that they are so heavily relied on to formulate policy as it relates to poverty and other programs for which eligibility is determined by income. I’m equally distrustful of CBO scoring in the current health reform debate but for a different reason. Changes in incentives change behavior but CBO doesn’t know how to score that with any precision. So, we are left with what economists call static (as opposed to dynamic) analysis which means as we change the rules like increasing taxes or cutting the price we will pay for drugs or other healthcare services, nobody will change their behavior and we can just assume we will achieve a proportionate increase in taxes or saving in healthcare costs. On the other hand, if we reformed the tort system, nobody can estimate with any precision how many fewer suits there will be or how much less defensive medicine will be practiced. So, CBO either assumes no savings at all or very little.

  22. archon41 says:

    Perhaps Margalit will some day reveal to us her vision of postcorporate America, and how, in the “transformational” era, incomes are to be determined.

  23. Nate says:

    besides reading the glossary did you read the rest of the bill? Nothing in there actually does anything, it talks about fraud and the need to do something and studying it but it doesn’t actually DO anything.
    For example Medicare and Medicaid lose about 10% to fraud and waste, if goverment is spending 1 trillion now of the 2.5 trillon annually that means they lose 100 billion to fraud. They propose spending 100 million. That is .0001 of total spening, that is a joke of an effort. They aren’t service about fraud they are giving it lip service.
    “I don’t think it inhibits insurance companies from steering people to less costly choices.”
    Steer them how? Asking nicely? Whats left if you can’t penalize or reward them?
    “Both public and private insurers could communicate information about utilization vs. others in the population of comparable age and health status.”
    We do this now for groups that are that aggresive in cost containment. We’ll do employee meetings and tell them their generic utilization is low or ER visits are high then discuss alternative options with them, this is usually in conjunction with a change in plan to “reinforce” the change, i.e. higher co-pays or cost sharing, unfortunetly the needed utilizers are penalized with the wasteful spenders.
    “This is not a small problem to be resolved by a bunch of community clinics.”
    Exactly right it can only be solved by people not having kids they can’t afford. The way you do that is stop with all the handouts and working the parent’s F’n asses off so everyone that knows them says G D I ain’t havin no kids till I can afford them cause it sucks working two jobs to pay mandatory support for my kids. With all the liberal charity and handouts you can live a very easy life with next to no works just by having a couple kids.
    Well said Barry

  24. archon, I have no desire to see a postcorporate America, whatever that may be. I hope corporations live long and multiply and all their owners and executives and shareholders become as rich as they desire. I just want their activities regulated so the rest of America, which supplies the means by which they get rich, also benefits from this prosperity. Call it responsible capitalism, if you wish.
    Nate, I guess you are pretty much politely rephrasing what South Carolina’s Lt. Governor, Andre Bauer had to say:
    “My grandmother was not a highly educated woman, but she told me as a small child to quit feeding stray animals. You know why? Because they breed. You’re facilitating the problem if you give an animal or a person ample food supply. They will reproduce, especially ones that don’t think too much further than that. And so what you’ve got to do is you’ve got to curtail that type of behavior. They don’t know any better.”
    I have no answer to that.

  25. Nate says:

    just repeating what I have seen in life. What I will say is it is enviromental and not genetic. I have seen the difference within families, kids of different age groups responding to their friends and what happens around them.
    Curious if you don’t have an answer to how to solve it or you don’t beleive it is true?

  26. archon41 says:

    Would you perhaps care to identify some of the countries where, by dint of “regulation,” great disparities of wealth no longer exist? Do you suppose Siemens, Roche, BP, Total etc. to be less focused on return on investment than their American counterparts?

  27. I don’t believe it’s true, Nate.
    archon, I have no problem with great disparities in wealth. I have a problem with exploitation and unbridled highway robbery. This country proved that it is possible to have a system that serves the wealthy and the citizenry well. I just don’t want to see it go away.

  28. Sharilyn says:

    My major stress about healthcare is the unfairness of it all … I have been told that patients without insurance have to pay in full the doctors’ charges while insurance companies enjoy paying a much reduced rate … on the average about 30 to 40 % less. I am one of the 48 million without healthcare insurance as we are owner/operators. We just cannot afford several hundred dollars a month for poor quality catastrophic insurance with high deductibles as I have been quoted … we are in our late 50′s and no company insurance available. Repairs/maintenance on our 2000 Volvo truck cost us about $18,000 last year alone, wiping out our savings! This healthcare crisis is a major stress to me as I still have 7 years before I can even qualify for medicare. My husband at least has the VA … I have nothing!

  29. I have been reading up on health savings accounts (as implemented by countries such as Singapore). Seems like an idea that could work (at least it does there). But, I am not sure how well it will work in the US. Maybe it’s another alternative. Any thoughts?

  30. Nate says:

    Curious Margalit how your ideal liberal healthcare system would deal with a person like this?
    http://news.ninemsn.com.au/world/1027360/woman-aims-to-become-worlds-fattest
    Should insurance companies be forced to insure this women at rates capped at some percentage of those not activly trying to kill themselves?

  31. Same way it deals with other people suffering from eating disorders and mental disease.
    And how would you deal with the vastly more prevalent situation Sharilyn is describing above?

  32. Rob Lamberts says:

    Sharilyn is describing one of my biggest frustrations: I can’t charge what I want. It has to do with Medicare’s rules as well as the contracts we must sign to accept insurance, not the greediness of docs. We cannot discount patients without either breaking a contract or breaking a law. If we discount below what we charge Medicare patients, we are breaking the law.
    Gosh, what would fix that….hmm….I don’t think anyone has talked about balance billing yet. If we were freed from the stupid rules that Medicare forces us to follow:
    http://distractible.org/2008/05/29/ten-dumb-things-about-medicare/
    http://distractible.org/2007/10/30/ten-facts-you-may-not-realize-about-medicare/
    http://distractible.org/2009/02/03/dear-mr-president-medicare-stinks/

  33. joe queen says:

    Will Jesus the biggest practicing Doctor of broken souls support a Socialize Health Care?
    My Kingdom does not belong to this world, Jesus said many times. We are a Christian Nation that committed horrible sins against native American Indians, Immigrants, and Slavery. Now we institutionalized denying health insurance to the sick. Is this a Christian Act. Is Jesus a for profit savior. Can Christians profit on the poor the insured. Jesus is beyond being a Republican and Democrat. If the Lord wants health care for the poor, he will touch the hearts of all the Congressmen he wants, He is the king, and nothing can stop him not Rush Limbaugh,not Fox News, not Obama nor the Democratic Party, he is the almighty, the omnipotent and omnipresent Jesus Christ my dear and beloved brothers and sisters in Christ. You see Jesus doing miracle in Hospitals, You see him in your operating rooms, he is everywhere and he is with the poor just be humble and remember your Lord and General Surgeon of the world and the United States the Lord Jesus Christ

  34. Nate says:

    And how would you deal with the vastly more prevalent situation Sharilyn is describing above?
    First by correcting here, she doesn’t have to pay full price. I have never meet a doctor that won’t give a cash discount close to equal to what insurance pays him or better.
    Next I would point out that for $10 a month or so she could buy access to those very same discounts insurance companies have.
    Next as a business owner myself I would say just becuase you want to be in business for yourself doesn’t mean your entitled to be in business for yourself. She comes off to me as downright selfish. Why should I pay for their choice to own their own business? If he is a half decent driver he could have a job with benefits in 3 ours. Hell I have 2-3 clients that would hire him if his record was half good.
    This is the problem with the left, your reform is built on lies and greed. She doesn’t have a problem with insurance she has a problem with the choices they have made and wanting someone else to subsidise them.

  35. TD says:

    Would someone please explain to me how it is that you think the current health care bill will eliminate any stress over health care costs? As I see it, it will simply spread more stress to more people by raising everyone’s premiums.

  36. Joseph says:

    Stress even affects ones fertility. What do you suggest to combat stress while planning a baby.

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