Uncategorized

From Pain to Poverty

“What am I going to do now Doc?” asked Mike, a down on his luck, 29 year–old recently unemployed truck driver, as he handed me his hospital bill.

Mike was seen at our local emergency department on a Friday evening with complaints of indigestion. Earlier that day he and his wife Susan celebrated their second anniversary by splitting a store bought pepperoni pizza. Mike had just lost his job and his wife, already working two jobs, managed to keep them afloat. When Mike later complained of indigestion, Susan became alarmed. She had just read about the symptoms of heart disease in the local paper. Mike wanted to get some antacids but Susan demanded he go to the hospital. Mike stated he initially protested, but when it came to his health he looked to his wife for advice.

He said he wanted her to drive him to the hospital and told me his wife wouldn’t hear of it. “We’re going to call 911, she told him. “You could die on the way to the hospital.” Now, Mike admitted, that made him scared and he quickly agreed. Fifteen minutes later he was on a gurney rolling through the double doors of the emergency department.

Physical assessment by the emergency resident physician came quickly followed by an EKG, chest x-ray, CT scan of the chest (“they said I might have had a blood clot”), and lab, specifically including cardiac enzymes. Mike said his only complaint was it took over five hours before he heard any news.

“Everything looks good,” said the resident. “Let me run all this past my attending and see if we can get you home.” Mike said by then his pain had been gone for hours and he relaxed by receiving the good news. When the resident returned, however, Mike said he knew something was wrong.

“Sorry Mike, but my attending thinks you need to stay for a chest pain evaluation, “ stated the resident with no hint of emotion. “Your first cardiac enzyme was normal, but he thinks you need another evaluation in six hours followed by a stress test, “ he continued.

Mike said he tried to protest. “But everything was normal? Can’t I just see my primary physician later,” he quizzed the resident. He said the resident looked down at his chart seemingly trying to choose his words and said, “Can’t be too careful with chest pain.” With that, the resident physician disappeared, followed by the nurse who quickly added insult to his non-injury.

“We don’t do stress tests on the weekends,” she explained. “The Hospitalist will need to keep you until Monday at the earliest.” Mike said upon hearing this news he protested, again wanting to just go home.

“Then you’ll have to sign out AMA (against medical advice). We can’t be responsible if you go home and have a heart attack and die,” she quickly added.

Mike said by then he was too tired to protest. The thought of dying at home also had him upset. He stated when he told his story to the Hospitalist, she just shook her head and laughed. “They just don’t want to get sued,” she explained. “We get these normal cases all the time. We try to tell them this can be handled on an outpatient basis, but what can we do?” She laughed again, which Mike took as a good sign he was really okay.

He left the hospital the following Tuesday—the heart scan machine was broken on Monday—with a clean bill of health and a diagnosis of “gastric reflux,” which I explained was the indigestion he first described.

I looked at his hospital bill. Charges for everything from the ambulance ride to the emergency department evaluation and eventual hospitalization with cardiac stress tests came to just under $11,000. This number was circled at the bottom of the bill with several question marks in red ink written to the side by Mike’s wife.

“We don’t have any money,” Mike explained. “Susan’s insurance won’t cover it, since we forgot to put me on her policy when I lost my job,” he continued. “We’re gonna have to file bankruptcy Doc. I don’t know what else we can do.”

What would have been a 15–minute office visit providing reassurance and education to a patient we knew quite well became a 72–hour ordeal by a health system treating a disease and not the patient, trading a patient’s pain for financial poverty. Surely we can do better.

On Labor Day Costs of Care asked doctors and patients to send us anecdotes that illustrate the importance of cost-awareness in medicine, as part of a $1000 essay contest aiming to shine a national spotlight on a big problem: doctors and patients have to make decisions in a vacuum, without any information on how those decisions impact what patients pay for care. Two months later we received 115 submissions from all over the country – New York to California, Texas to North Dakota, Alaska to Oklahoma. We feel these stories are poignant because they put a face on some of the known shortcomings of our system, but also because they unveil how commonplace and pervasive these types of stories are. According to essay contest judge Dr. Atul Gawande, a surgeon and staff writer at the New Yorker, “These [stories] are powerful just for the sheer volume of unrecognized misery alone.”

Livongo’s Post Ad Banner 728*90

Categories: Uncategorized

Tagged as: , , ,

48
Leave a Reply

48 Comment threads
0 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
15 Comment authors
Sue ShortAl KennedyMargalit Gur-ArieMt DocPaolo Recent comment authors
newest oldest most voted
Sue Short
Guest

It’s unfortunate that the fear of scenarios such as this keep many uninsured folks out of hospitals and doctor’s offices these days. Staying healthy takes on a whole new meaning if getting sick means either paying extreme charges or waiting it out without knowing if something worse is going on.

Al Kennedy
Guest

Interesting Blog, even though this was not what i was looking for (I am in search of clinics like this one> http://www.ccsviclinic.ca/ )… I certainly plan on visiting again! By the way, if anyone knows of a good clinic that does CCSVI Screenings? BTW..thanks a lot and i will bookmark your article: From Pain to Poverty…

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

“To a point. Governement run/controlled systems work with for-profit providers but control prices. Hospitals should be community owned non-profit with strict budgets that medical staff and administrators need to meet. No Taj Mahals and bonuses for revenue generation.”
You do realize, tho, under that system, medmal as we know it is out the window, right?

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

Wow. We actually agree on something. =D

Peter
Guest
Peter

“That, and for-proift medicine. And for-profit insurance. Get rid of all these and watch the money get saved.”
To a point. Governement run/controlled systems work with for-profit providers but control prices. Hospitals should be community owned non-profit with strict budgets that medical staff and administrators need to meet. No Taj Mahals and bonuses for revenue generation.

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

No, every patient I see is not a potential law suit. But, I don’t know which ones are the potential lawsuit, and which ones aren’t. So, I got to treat them all that way. “That’s wildly exaggerated. According to the actuarial consulting firm Towers Perrin, medical malpractice tort costs were $30.4 billion in 2007, the last year for which data are available. We have a more than a $2 trillion health care system. That puts litigation costs and malpractice insurance at 1 to 1.5 percent of total medical costs. That’s a rounding error. Liability isn’t even the tail on the… Read more »

Peter
Guest
Peter

“But critics of the current system say that 10 to 15 percent of medical costs are due to medical malpractice.” “That’s wildly exaggerated. According to the actuarial consulting firm Towers Perrin, medical malpractice tort costs were $30.4 billion in 2007, the last year for which data are available. We have a more than a $2 trillion health care system. That puts litigation costs and malpractice insurance at 1 to 1.5 percent of total medical costs. That’s a rounding error. Liability isn’t even the tail on the cost dog. It’s the hair on the end of the tail.” “You said the… Read more »

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

@DeterminedMD I thank you for your compliments, but honestly doubt I deserve them. I haven’t done that much missionary work. As for the insurers and lawyers amongst us, well there will always be parasites in the world. If you are not a doctor, a nurse, a tech, or an allied health professional, you really don’t provide any health care and are just a parasite on the system. Just keep in mind that we are the good guys and they are the bad guys. It won’t make you much money, but will make you happy with your own existence. Money can’t… Read more »

DeterminedMD
Guest
DeterminedMD

Again, stop engaging this guy, Dr Vickstrom, I am beginning to wonder if he is not a covert operative for the legal system, or at the very least one of these annoying “devil’s advocate” debaters who just argue for the sake of keeping the dialogue up. In tune with that comment, I read your above comment about what your professor preached about patients looking to “slit your throats” and have to note a sizeable number of lawsuits are not intiated by patients, but, by the greedy bastards of the legal profession who talk patients/families into pursuing suits just because the… Read more »

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

@Peter, “So, you do all those tests because you don’t want the inconvenience of going to court once every 10,000 patients?” Yes. Being accused of a crime you didn’t commit, and being held responsible for things you cannot control is not an “inconvenience.” The hate and rage this inspires in someone with even a smattering of a sense of justice and self-respect is incalculable. A medmal lawsuit may be just a business transaction to you, but to me it’s a question of honor and competency. In the medical profession, the stupid, the lazy, and the ignorant are looked upon as… Read more »

Peter
Guest
Peter

“If the patient were the one in ten-thousand case where the pain was cardiac and an adverse event would have occurred, the doctors would have wound up in court trying to explain to a lay jury why they didn’t admit the patient etc.”
So, you do all those tests because you don’t want the inconvenience of going to court once every 10,000 patients? Exactly how many years would it take for you to see 10,000 patients?

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

@Peter, The author of that article has his thoroughly up his rectum. If he thinks that a couple little tort reform laws are going to change a cent, he is wrong. To change medmal, we are going to have to change society’s expectations of medicine. We are going to have to change who sits in judgment over what is a mistake and what is not. Then, we’re going to have to wait a generation for guys like me to get old and retire. The socialist in me also argues we have to remove the profit motive from medicine, completely. Because… Read more »

Margalit Gur-Arie
Guest

“To act conservatively would save the patient some money, but if you’re wrong the patient could suffer and you’ll wind up in court.” At point does the concern shift from patient suffering to winding up in court? I do understand the over-utilization, or perceived over-utilization problem, but it is hardly the biggest problem we have. Every day millions of folks have chest-pain-heartburn symptoms. Most just swallow some chalky liquid or pill and move on. Few die because they misdiagnosed themselves and few others panic and go to the ER. Is this really breaking the bank? Or perhaps the fact that… Read more »

Mt Doc
Guest
Mt Doc

Most doctors would probably say that a reasonable standard of care in this case would have been to do the initial studies in the er to rule out a cardiac etiology for the pain. At that point the risk assessment would suggest a very low probability that the pain was cardiac and a very high probability that it was due to reflux, and the patient could have been discharged on therapy for this. Note the operative word “probability”. The problem is, as other doctors have pointed out, that society is not interested in probabilities, it wants certainty (or as near… Read more »

Peter
Guest
Peter

Found this educated and level headed view of tort reform, obviously done by someone without his head in his recta.
http://prescriptions.blogs.nytimes.com/2009/08/31/would-tort-reform-lower-health-care-costs/