SOAP 11/2017

[Kalyan Sreeram]

S: One of the greatest points of contention for American consumers of healthcare and the services provided is the inconsistent return on costs incurred for them. The bills often show up as astronomical amounts for minor or basic tests/procedures, and insurance structures are aimed at diminishing those amounts. Yet the costs can still be out of control. Part of the problem is that there aren’t consistent costs or insurance coverages for services rendered, so it is therefore nearly impossible for healthcare providers to even help the consumer understand how much their bill will come to be. It is obvious that with a growing aging population, the costs toward providing the same levels of healthcare are only going up. Knowing there are only more limited resources per capita and sicker populations due to multiple factors, it is fair to question exactly what level of healthcare is a right and which interventions are of privilege, while taking the context behind providing therapy into place.

I feel confident in my knowledge of the healthcare system from a standpoint of acute service delivery and guidelines. The same does not quite apply for chronic management, and that is in part due to the inconsistencies present in trying to account for services as they are delivered over time. From a purely clinical standpoint I do not think there is a healthcare system that can stand alongside the US system, but I think our system suffers from finding an affordable way to provide basic services for everyone.

O: I once had a vasovagal episode during my third year pediatrics rotation in the Newborn Nursery, and before I knew it I was wheeled down to the ER (I was completely fine by the time we got there). Still, I figured they would give me an EKG and draw basic labs (which they did), none of which showed any abnormalities. They gave me an orange juice and graham crackers, and let me go my way once my condition was confirmed as okay. By the time I got the bill, I saw it cost $700, and still came to $500 after insurance coverage! I never even realized I could refuse care AMA, but now I wish I did since the bill came back the way it did.

In contrast, I once had a patient who kept coming in for emergent dialysis because he would just keep smoking crack at his homeless shelter, go into flash pulmonary edema, then act as an absolute terror on the floor, be discharged, and come back every few days for the same thing all while angling to leave AMA. That patient never had to pay a cent for his healthcare because everyone else pays for it due to Medicaid. Yet we as practitioners are obligated to help such patients because we are inclined to do no harm. On the other hand, in my case I was lucky I could afford to pay for the service, but many well-meaning and hardworking insured people are not fortunate enough to afford such costs.

I think the two stories above when juxtaposed are telling about the holes in insurance coverage. I will never regret giving the nonadherent patient appropriate care in a vacuum, but I do regret that providing him care takes away resources that would be much better spent on a patient who is suffering, hardworking and motivated to adhere but is thrust into an unfortunate health circumstance.

A/P: Right now we are in a precarious situation as consumers of healthcare; we often cannot estimate how much our costs will be.
To combat this, it ALL will come down to how well-informed patients AND providers are about the healthcare system. I vow to constantly try to understand exactly how much tests cost, and plan to follow the “Choose Wisely” guidelines to the best of my knowledge for the sake of my patients. I will commit myself to enhancing my clinical knowledge at every juncture, for that will come in handy to help my patients receive efficient care. It will also require me to understand my patients beyond their clinical/pathophysiologic context; I need to understand their social determinants of their health as intricately as possible.

Primary preventive healthcare (and other inhernetly indicated procedures) should be a right for everyone, but only provided patients demonstrate personal responsibility for their care. One good example of this is the controlled substance contracts in GMAP clinic. I would like to see the spirit of this intervention more widespread toward general medical conditions one day, even as a tacit understanding. Just as we expect our patients to hold us as providers accountable, we need to be able to do the same for our patients. If we can all do so, then I think we are closer to seeing healthcare become a more affordable service.

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