POLICY: The real costs of uninsurance, by Anonymous, with quick UPDATE

Every so often it’s worth remembering the human and economic costs behind our uninsurance statistics. The following TCHB contributor was employed and insured until about a year ago, but like many with her health condition cannot afford insurance now she’s uninsured. I’ve kept the author anonymous for obvious reasons, although she lives in the San Francisco East Bay, but read on and you’ll understand why there are economic costs for all of us from the uninsurance numbers:

I recently had my own health care crisis, and I thought I’d share it with you as something to ponder. I don’t have any context to put it in, so I will leave larger analysis to you. My basic reaction, though, is that as relieved as I am that I had access to good care, the whole process was utterly stupid from the taxpayer point of view.

A few weeks ago I had a large hemorrhage in one eye. This is a harmless condition for most people, but I was worried because I have an underlying genetic condition that causes a form of macular degeneration, and I was worried about hemorrhaging that I couldn’t see in the area of my retina. If this was the case,time was of the essence if I didn’t want to lose a chunk of my vision.

It was 2am when I discovered the problem. I’m uninsured, but I knew that an ER would have to treat me. I walked to Alta Bates in Berkeley. As a pathetic side note, I went to the wrong Alta Bates campus – I then had to walk to the Alta Bates with the ER (on Ashby). By the time I got there, I had a lot of pain in my legs (the same genetic condition causes claudication), and I had trouble explaining to the nurse that while I was limping and in tears, this was normal for me and was not why I needed to see a doctor. 🙂 The only reason I’m relating this is that I don’t think many people think about how poor people go through to actually get to the ER in the middle of the night in the first place.

I was treated very well as a person at Alta Bates. They didn’t make me feel uncomfortable about my lack of insurance at all. They gave me charity forms to fill out. I waited 5 hours to be seen, which turned out to be normal for both Alta Bates and Highland. The initial doctor I saw at Alta Bates did not give me adequate care. She glanced at my eye and told me there was nothing to worry about with that sort of hemorrhage. Since I provided information on my underlying condition up front, she should have given me a thorough eye exam. This visit cost the taxpayer $356.00 for the ER plus whatever the physician fee is (probably around $200.00).

I know enough to test my eyes myself, so the next day I tested myself. My vision was distorted. I tested over and over again just to make sure: I certainly didn’t want to go through the ER experience again. But the tests were always the same, so I went back to the ER. That’s a second $356.00 (possibly more for ophthalmology set up) plus the physician fee. This time Alta Bates gave me an urgent referral to Highland Hospital. Highland has an ophthalmology clinic, and a program for indigent patients. Highland, however, didn’t want to take the referral. It was written on my aftercare instructions instead of the form they wanted. I called Alta Bates to ask for the right form, and they insisted I was holding the referral. I called back and forth all day. Alta Bates finally faxed the referral, and Highland said it would
be at least three days before they could verify they even got the fax(!). This referral had urgent written on it because the Alta Bates physicians thought I needed to see a specialist fairly quickly. At one point I called Berkeley Free Clinic to see if I had any other county health system options for ophthalmology. Highland unfortunately was the only place for me to go.

An Alta Bates nurse then advised me to go back to Alta Bates, get a copy of my medical records, and go to Highland Urgent Care so a Highland physician could refer to the ophthalmologist. That’s right: my THIRD 5-hour emergency room visit for the same problem. The taxpayer was unnecessarily triple-billed because of some bureaucratic issue.

With travel, the trip to Highland took a spectacular 9 hours all together (I’d never been there, and two successive bus drivers forgot to tell me where the stop was). Once again, I have no complaint about my treatment as a human being. I described my situation, and the insurance person didn’t bat an eye. She just gave me the forms to fill out.

I was also very well treated by the triage nurse at Highland. After I told her about the problem with the referral, she physically tried to run after the on-call ophthalmologist. I almost lucked into seeing him right then and there, but he had to go into surgery. He did however give the triage nurse an appointment for me on the spot.

A morning later, I took another trip to Highland. The wait in the ophthalmology clinic was down to an hour. The ophalmologist gave me some tests, took a look at the area of my eye that was the source of distortion, and confirmed it wasn’t actively bleeding. (Keep in mind that I had gone through the past few days under continual fear that I might be losing my sight minute by minute). So, big relief. He thought the distortion was being caused by blood vessels and/or related scarring. It might have actually been there for months: I just never noticed it without the tandem visible hemorrhage. As a member of the uninsured, I had not had access to regular ophthalmology checks that are really necessary for someone in my condition.

Perhaps an economic analyst like yourself might realize that the public issue here is that denying me health care in the first place (especially in a frivolous “specialty”) means that the taxpayer gets to pay long term when I’m permanently disabled.

While I wasn’t in an acute situation, my vision was still damaged. The ophthalmologist referred me to a retinal specialist at Summit. This retinal specialist was supposed to give me an angiogram to show whether blood vessels were the issue, and whether my vision could be helped or at least prevented from deteriorating by laser surgery.

The good news for me as an indigent patient is that I was sent to the same retinal specialist that anyone else would go to. The bad news for the tax payer is yet another weird system disconnect occurred. I went to the retinal specialist, but I didn’t get the angiogram. I got the exact same eye exam I got from the ophthalmologist instead. Afterward, the retinal specialist gave me a rerun of the angiogram and laser surgery talk. He needed to schedule me for another appointment for those. The appointments system was down so the nurse was supposed to call me. My phone is sketchy, so I gave my email as well. It’s been a few days, and I haven’t been contacted by either phone or email. I plan to call after I finish this note.

So many things have been surreal about this entire situation. I was honestly surprised that the people dealing with the insurance forms were all non-judgmental and dealt with me in private. This would not have been the case in my home state of Virginia, where the economy is regulated through shame. 🙂

On the other hand, the actual medical care varied, and it required a lot of proactive work on my part (to negotiate between Alta Bates and Highland). This was difficult for a fairly well-educated and strong person like myself: I wonder what happens to people who are more docile or more acculturated to conditions of poverty. I thought that the first doctor in the Alta Bates ER should have taken a closer look at me, but all the other doctors I saw were great.

It was also stressful to go through all the bureaucratic hassles at a time when it was possible that every minute could be costing me more of my sight. The initial trip to the Alta Bates ER actually gave me a fever – some sort of shuttle between hospital campuses would have been nice. Also, I had to deal with a guy following me and making catcalls as I made my way back home in the wee hours of the morning.

Finally, the redundancy was mind-boggling. It’s a good thing I don’t work at all, because I literally spent half my week in hospital waiting rooms. If I were temping at the time, I would have been out of a job that at this point I would be desperate to cling to. I appreciate that no one cares about the wasted time of a non-entity such as myself, but when you realize that each trip was a *separate* bill to the taxpayer, it might be time to start considering this as a social issue.

This story is not over yet: I need to go back to the retinal specialist, and then probably some laser thing after that. Hopefully, there won’t be any further adventures in nonsense. I will try to remember to let you know if I get to a point where I can total up a final bill.

The only point that is not accurate here is that the taxpayer per se won’t get these bills–they’ll probably be marked down as charity care, after the hospital makes some level of effort to get the money out of the patient. And of course $350 is the rack rate for an ER visit, not what a local health plan would pay. But in the end, we’re all picking up the tab for this foolishness–now and in the future.

UPDATE: The Sunday Boston Globe had an article about a guy who played the uninsurance gamble and lost, and now has to pay Mass General $40,000, where an insurer would have paid them $7-10,000. The key part is that he’s paying off his bill to the General at $700 a month — which is what insurance from Blue Cross would cost him. Prize to the first person who can email me the 5 counteracting incentives in the whole system this article details without having their head explode.

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