OP-ED

N = 1 My Experience with the New Health Care System

“You look nice today. People don’t come to chemo in suits very often.”

The friendly and familiar receptionist mentioned as I was checking out, the always full jar of lemon flavored hard candy on the shelf between us. As I pocketed a few of the candies, I managed to swallow the nausea and metallic taste just enough to say, “Thanks. I have a job interview today.”

During my senior year in college, with medical school acceptance letter in hand, I was diagnosed with metastatic testicular cancer. Initially, life became planning surgery and meeting doctors, but early in my treatment course I received a letter that my health insurance had been exhausted and I would no longer receive any health benefits. This was after my first of four chemo cycles, with a major surgery still to come. Needless to say, this was a problem. My parents were both well educated, a lawyer and a chemist-turned-teacher, but this took everyone by surprise and presented a new crisis.

We responded by dividing up tasks. My parents quickly inventoried all the assets, including the family home, and my sister called around to all the hospitals to see what could be done.  She called the local and state governments asking for advice while I simply tried to eat food and get to class to graduate on time; I couldn’t have another tuition bill on top of my health expenses. I also started to look for a job, with a job came insurance – this much I knew.

I went to the interview, a job as a management trainee in a car rental agency, with hopes that this job would be something I could get, could do during treatment, and would provide the insurance that would save my family from financial ruin at my hands – my disease. I went to a Jesuit college and learned that truth and honesty are paramount.  So, I told the recruiter that I had cancer, I was in treatment, and that I would likely be done soon – all true.

I didn’t get the job. I still didn’t have insurance and my next chemo session, with its massive bill, was coming very quickly.
My sister learned that this would not be fun. One hospital said to her that they would treat me and then take us to court to get paid. Thankfully, I went to school in Massachusetts where a law was on the books that allowed me to enroll in health insurance without a pre-existing condition exclusion because my insurance being exhausted counted as a special qualifying event. I enrolled in an individual insurance plan, my care went uninterrupted, and I graduated on time. To this day, my sister and I remain grateful to Massachusetts for that single law, which is as much a part of my success as cisplatin and etoposide, the chemotherapy agents I received.

The bills still mounted, but were manageable. I survived, personally and financially. I pushed off medical school for a few years to get my life back in order, and moved on. I had many scary moments during my treatment, from the plastic surgeon telling me my arm might need amputation to my neutropenic fever to being discharged just in time for my college graduation.  However, what bothers me the most was, and stillis, the sense of abandonment from my society when my insurance ended.

I had insurance, my parents had good jobs and were highly educated, so how was I left in the breeze?

Now that I’m well past treatment, married to my then-girlfriend with two beautiful children, and currently a practicing physician at a major university, I still find myself troubled by the “Fogerty insurance debacle of 2002.”

With all the talk about health reform, I always kept quiet in the back as those around me in residency (which I completed in 2011) offered their opinions, and I realized that most of my colleagues were blissfully ignorant as to the financial burden of major illness. Between my own illness and my residency graduation, I also lost both my parents, got married, and had my first child.  By my early 30s, I’d experienced healthcare as a provider, patient, son, husband and parent. Generalizations are always dangerous, but I felt as though nobody around me understood the financial impact of this massive industry.

This gap in knowledge bothered me, so when I finished my training and joined the faculty, I dusted off my Economics degree and did something about it.

Residents and medical students that are still in-training are entering a new world of healthcare, one where financial ignorance is no longer permitted. My small part is to begin and remove the blinders, to expose them to the other stress in their patient’s experience. There are safety issues and financial waste throughout our system. Bringing these to light in an educational sense provides me with personal and professional satisfaction.

What did this Massachusetts law mean to me? When I recovered from my disease, my family and I had taken a physical and financial blow, but we could recover. Two years later, with my credit intact, I was able to borrow money to attend medical school. Without insurance, this never would have happened. There is more to surviving disease than outliving the pathology. The financial scars of medical care can be just as disabling to survivors of any disease, and as we grow and change as a profession, it is important that our providers of the future, today’s residents and medical students, have an understanding of the financial realities of their jobs.

Robert Fogerty, MD, MPH is a practicing Hospitalist in New Haven, CT and Assistant Professor at the Yale School of Medicine. The views here are his own. This piece originally appeared in Costs of Care.

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Catherine Nichols Pogorzelski
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Catherine Nichols Pogorzelski

Mike B, what type of doctor might you be? Care to give a stab at diagnosing me?

Catherine Nichols Pogorzelski
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Catherine Nichols Pogorzelski

to: Mike B & Barry Carol: First, let me agree with Barry Carol, in that there is no “Board Certified Diagnostician” specialty and therein lies the rub to getting proper diagnosis as wella s proper treatment. hte res of this long post is to Mike B: A PARODY OR PSYCHOSIS?! This was in no way an “attempt” at parody/humor, NOR am I PSYCHOTIC, this is MY REALITY! Check my FB page from time to time. I may be speaking in a mordant manner, but I assure you, this is all REAL (come visit and I will show you reams of… Read more »

Catherine Nichols Pogorzelski
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Catherine Nichols Pogorzelski

It must be nice to be able to go into a doc’s office, get a PROPER diagnosis, then PROPER treatment, I applaud your tenacity, mine’s hanging by a thread; because your neck of the woods doesn’t even WANT to acknowledge that a NEW disease process exists , a ‘la “NON-Nephrogenic Systemic Fibrosis.” (see Cowper, down the block! & Kay, being late for an appointment after driving 500+ miles, because another Robinson doc kept me tied up-I was refused my appointment!) How about those who HAVE GREAT insurance, yet who are irreparably harmed by 22+ years of undiagnosed Lyme Disease, additionally… Read more »

Mike B.
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Mike B.

If this isn’t a parody, it’s just sad.
(Distinguishing parody from psychosis, on a site you don’t expect attempts at humor, is hard to detect.
And having had to deal w/ patients like “CNP,” it’s hard to find it funny — if that was the intent — in any event.)

Barry Carol
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Barry Carol

Peter1 – The trend is to move away from the fee for service payment model in favor of bundled payments for surgical procedures, shared risk / shared savings models for hospitals, and, eventually, capitation or global budgets for hospitals. The Accountable Care Organization structure would lend itself to this approach pretty well, by the way. For hospitals, to the extent that they get paid largely based on DRG’s (case rates), reducing unnecessary testing would save money for the hospital without reducing case rate revenue. Eliminating the entire DRG, though, because it’s unnecessary or marginally useful is a different matter. When… Read more »

archon41
Guest

“Reducing unnecessary testing” brings us back to the to the threat of tort liability. Each patient is, at least in court, a unique individual, with individual needs, not a cypher in a protocol digest. Under existing law, the courts frame the issue in terms of foreseeability. All the plaintiff is required to show is that the physician “should have known” that the test deemed “unnecessary” under protocol would have averted the outcome complained of. As for changing the existing laws relating to “negligence,” I see little likelihood of that.

Sandra_Raup
Guest

Does it make sense to have global budgets for hospitals rather than an overall global budget for the country or region by region? What happens if it’s a global budget for a provider type, costs just get shifted to another provider (note rehabs and TCUs that take care of post-op care, with hospitals still getting their DRG payment that used to include much more time in the hospital). There are ways to manage an overall global budget – that does require rationing as it’s commonly understood, but what also happens is providers start to understand the “scarce resources” approach and… Read more »

Barry Carol
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Barry Carol

Sandra – I don’t see how you could impose a regional global budget when providers are controlled by different corporate entities. I also think it would be hard to get doctors to practice more efficiently, especially regarding the ordering of diagnostic tests, when the hostile litigation environment hasn’t changed. If there is a public perception that doctors aren’t allowed to miss anything or should have known that an extra test might have led to a timely diagnosis, they are going to practice defensive medicine. It pervades the medical culture. It’s different in the UK where the NHS pretty much runs… Read more »

Sandra_Raup
Guest

The rest of Europe uses insurance, not a top down approach. And the UK isn’t as prescriptive as it sounds. They use a supply side approach – fewer ICU beds and dialysis spots; number of physicians that are trained; number and size of hospitals. There are interesting approaches to supply and costs – trained nurses colonoscopies, and, as one primary care physician in the UK said, “If you’re asking if we let someone with kidney failure die, the answer is yes, but everyone who needs dialysis gets it.” It seems to be playing out a bit here – some recent… Read more »

Peter1
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Peter1

Sandra & Barry,

I can speak to how Canada does it. The provinces administer their own health insurance “federal” plan with universal budgets, but the federal government also uses transfer payments to control compliance – much the same way the U.S. uses highway dollars to regulate state standards. But of course there are no “private” hospitals – an easier system to regulate.

The U.S. will never get control of health costs with so many private interests working at cost purposes to cost control and the ability to find loop holes.

More info here:
http://mapleleafweb.com/features/canada-s-health-care-system-overview-public-and-private-participation

Barry Carol
Guest
Barry Carol

“It is questionable whether Congress even has the lawful authority to abrogate rights well established in the common law.” archon41 – I don’t agree. What right does a patient have to sue a doctor for not diagnosing cancer three months sooner because the doctor failed to order that one more test that evidence based guidelines and protocols didn’t call for? There was a time in the 1980’s and early 1990’s when lawyers were bringing many class action suits against publicly traded companies basically because their stock went down when sales and earnings results fell short of expectations. It was often… Read more »

Peter1
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Peter1

“if it did, we could get some useful experience to see whether or not such protection would actually reduce defensive medicine, at least over a period of five or more years as doctors gained confidence in the law’s protections.”

Yes Barry, I’d be willing to test as well. You’re assuming that docs are chomping at the bit to reduce health costs overall through evidence based medicine.

I suspect that docs in hospitals will have a harder time as it will reduce hospital revenue. Hospitals may just increase charges elsewhere to keep the billing machine fed.

archon41
Guest

Given the chokehold lawyers and their accomplices have on us, providers can expect no meaningful relief from the existing tort liability scheme. It is questionable whether Congress even has the lawful authority to abrogate rights well established in the common law. Denying the relation between “defensive medicine” and the threat of tort liability, however, was essential to the passage of Obamacare. This denial made plausible, to a crucial segment of the electorate, the claim that the high cost of health care is due primarily, if not exclusively, to the “greed” of insurers. This gave rise to the agreeable notion that… Read more »

Joel Hassman, MD
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Joel Hassman, MD

A person comes to this thread and reads what, more of the rigid zealot ideology that drives either abandonment or dependency.

Oh, and the usual antiphysician drivel that tried to hide as being “sensitive” and allegedly focused on the needs of the public.

Yeah, well “bunk” to you antiphysicians, although many who know they are just project their selfish and special interest agenda on doctors as a whole.

MD as Hell, you know this mob who trolls here and what they want.

Us to wear black and white collars and embrace that vow of poverty.

Just so the antagonists can take more money and power.

Bobby Gladd
Guest
Bobby Gladd

How poignant.