[Yellow Cohort] Module 4

[Adam Qazi]

Please submit SOAPs for Module 4:

[Nabil Al-Kourainy]

Social Determinants of Health #4 Reducing waste by limiting duplication of tests/imaging

S: After reviewing the case and watching the Ted talks I found waste to be a salient theme. This week in clinic a encountered a pt which is prototypical for this epidemic problem in medicine. Pt is a 57 year old male with a PMHx of uncontrolled HTN, 2 recent ED visits for “…way too high blood pressure” nicotine dependence disorder 20 PY, as well as lumbago who presented for hypertension follow-up. Pt endorsed chronic productive cough x 2 + years, dyspnea upon exertion, <4 mets, limitations to physical activity due to SOB, orthopnea, but denied PND O/E he had a loud P2 and S4 (EKG was significant for LVH). He also endorsed chronic constipation and several episodes of BRBPR. He further endorsed some memory loss with a questionable history of CVA. Pt was unsure of the dates of his ED presentations and was not entirely sure of which hospitals he went to.

O: According to Stewart et al A preliminary look at duplicate testing associated with lack of electronic health record interoperability for transferred patients “…transfer of records containing important clinical data is imperfect when patients are transferred from one healthcare institution to another, resulting in duplicate testing—even when both institutions have electronic record systems. An opportunity exists to improve timeliness of care and decrease through implementation of interoperable electronic health records (EHRs) between institutions.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2995707/ This was in fact the premise behind the EHR system. The original proposals described a universal system (as echoed by Mr. Hupfeld) where systems had cross-compatibility and could freely communicated with one another. Unfortunately, the only EHR which exists that even comes close to the ideal exchange of information is the VA EHR, which by nature of it being the nation’s first EHR, is unfortunately outdated and lacking in essential features. Just as Dr. Wen eluded to in her discussion of the parallels between the Chinese system of health care and the U.S. healthcare system, a system that is based on entirely on the free market incentivizes not only duplicate examination, but unnecessary ones as well as questionable procedural practices.

A: When I asked if he had previously had any studies: CXR, CT scan head, TTE, PFTs, Colonoscopy he could not definitely state what tests he had previously had and which he had not. Given his symptoms and lack of ability to determine when, where and if he had any of these tests in the past, and no access to outside records other than Cerna, which unfortunately yielded no results, I was faced with a dilemma – to potentially re-order examinations the pt had already had, and further contribute to the medical duplication epidemic, or to hold off and attempt to acquire outside records through an exhaustive barrage of requests from the hospitals within a 25 mile radius of the pt’s home.

P: While staffing my pt with the attending, I expressed my concerns about the potential for duplication and medical waste associated with re-ordering studies that my patient likely had previous had. We decide to try to mitigate this concern, that we would only order the tests that we felt were absolutely necessary and pertinent to the pt’s presenting signs and symptoms. Given the fact that O/E my pt had a loud P2, S4, and LVH on EKG and his activity and quality of life was being limited by his symptoms, we opted for a TTE, which even if he had previous had in the past, it would be clinically indicated to repeat, given his recent decline in functional status. Due to his respiratory complaints and history of nicotine dependence, and OE prolonged expiratory phase, we performed a in-office PFT. This was unfortunately inconclusive so we opted to obtain a CXR and outpt PFT with lung volume assessment. We decided to hold off on further imaging and screenings until his next visit, where in the interim, we would work to obtain medical records from the hospitals that the pt could remember he presented to. In making this decision, we achieved a balance, addressing the acute needs of the patient, while limiting duplication in testing and imaging.

[Jie Chi]

Social Determinants of Health #4 Lack of health insurance

S: After reviewing the case and watching the Ted talks, I found it interesting to compare medical systems in US and China. Compared to China, US produces most of the research, innovation and technology that improves health care throughout the world. Americans have more choice of physicians and treatments than patients in any other countries. But the cost of health care is extremly high. On average, health insurance in New York now costs nearly $6,000 for an individual and $16,000 for a family, more in New York City. At the same time, too many Americans remain uninsured. Like it was stated in the module The Kaiser Commission has reported that 26% of uninsured adults have forgone care in a prior year because of cost compared to only 4% of adults with private coverage, and 55% of uninsured adults report no regular source of healthcare.Certainly, lack of health insurance is a significant barrier to healthcare. The Kaiser Commission has reported that 26% of uninsured adults have forgone care in a prior year because of cost compared to only 4% of adults with private coverage, and 55% of uninsured adults report no regular source of healthcare.

O: lack of health insurance is a significant barrier to healthcare. Nearly all the growth in the number of uninsured people (which has swelled from 40 million in 2000 to almost 47 million in 2005) is among those aged 18 to 64, most of whom are working, says Davis in “Uninsured in America: Problems and Possible Solutions” (BMJ, Feb. 17, 2007). Much of the increase is due to employers cutting back on coverage and benefits in response to rising costs and adverse economic circumstances. The consequences of this failure to provide universal coverage are dire: lost lives, decreased economic productivity, underuse of essential services, and inefficient and poorly coordinated care.

A/P
In China, health care policy has focused on extending medical insurance coverage into rural areas and strengthening service delivery: more doctors, more beds, more funding. Big accomplishment has made due to the much lower cost of medical bills. However this could be impossible in the US given the high cost of medical bill. For the medical system in the US, it would be ideal to move away from a system dominated by employer-provided health insurance and instead making health insurance personal and portable, controlled by the individual rather than government or an employer. Putting workers in charge of their own insurance would significantly reduce the cost of insurance, this also increases competition in the insurance market.

[Deya Obaidat]

coming into the US healthcare system I’ve always imagine that its going to be all about patient centered system, where the money doesn’t really matter when it comes to a patient safety and life, coming here and be part of it was a total different story!! I started to realize that the healthcare in here is super expensive unless you have an insurance and specially in Detroit where there is a lot of poor population who are unemployed it could get really difficult for those people to see a doctor to begin with unless there disease is very severe that they have to go and see the doctor because they will be afraid that they are not going to make it this time and once he come and see the doctor sometimes its going to be late and the disease will be beyond the medical management unfortunately. and i feel part of the reason why the healthcare is very expensive in here is that doctors do a lot of unnecessary investigations for the patients, and the reason behind that is that the healthcare providers are always afraid of the possibility of missing something that the patient might later on sew them for!!

I had a patient in my clinic this week who came in for a follow up visit, last time was seen 1 year ago, he was on 8 drugs according to the previous note that i’ve read, this patient initially was asking me to refill one of his blood pressure medications, and he was saying that he is only taking this medication and nothing else, when I was looking into the patient’s chart, he had an extensive morbidities and had major surgeries in the past, and originally supposed to be on 8 different important medications that have been proven to decrease the mortality rates in the patients, and when i asked him about the reason behind that, he said that he couldn’t afford to come to the hospital because he has no insurance which is the same reason why he didn’t check up in the clinic in a whole year.

the healthcare cost and insurance is a one complicated subject where it has significantly affected a lot of people health along the years where they’ve had less care and more disease if they lack the insurance appropriate for that.

It might be hard for one like me to solve the whole problem as a person, but I think that we should always work together, not only as physicians, but as a community, which will include policy makers, insurance companies and law forces to work with each other to have a better understanding of the healthcare and how can we make it a better option for those who are in need of it. as a person I’d always make sure that I will make my investigations appropriate to the patient’s condition, not less or more to make the cost of the patient’s visit as little as possible.

[Shivani]

S: Lack of insurance coverage causes difficulty in access to care. Patients have intermittent care and miss out on necessary testing. However, in the example in the video presented by the doctor about her mother, her family likely has access to care /resources. She is faculty at an Ivy League Medial School, she has many colleagues who are experts in their field. Although her mother had a bad outcome, it likely was not due to lack of available resources compared to many patients we see in our clinic.
O: I saw a patient in clinic who needs a colonoscopy due to abnormalities found on a previous screening colonoscopy. He has insurance and seems willing to get the test again. However, he does not have reliable transportation to the test. When I talked to him about it, he said he does not have any friends/relatives who could transport him for the test and wait for the procedure. He said previously the colonoscopy team was able to arrange for a van to take him to the test and bring him home. I encouraged him to speak with his insurance and GI provider to see if there are any options for him.
A/P: It is important to take into consideration a patient’s potential barrier to care. Also, it is important to discuss risks/benefits/alternatives into consideration. However, the ultimate decision is up to the patient.

[Marvin Kajy]

S: Many people around the country struggle with access to healthcare. Nowhere is this more evident than in our patient population. It is truly heart breaking to hear some of the people’s stories. For example, I have seen a diabetic patient who had sustained an infected toe ulcer and did not present to the hospital early on. In stead, he opted to wait hoping that it would resolve on its own. Instead, the ulcer got worse and the toe became gangrenous and eventually requiring amputation. Similarly, I have seen so many young people in their 30’s and 40’s on dialysis. They developed end stage renal disease due to uncontrolled hypertension. These are examples of problems that could have been avoided had they sought care early on.

O: It is very well known that spends the largest amount of money on health care than any other nation on Earth. However, according to the World Health Organization its health system is ranked 37th in the world. This is obviously a major discrepancy and one has to wonder why. Many law makers and economists have attempted to answer this question and the cause is multi factorial. One factor is inefficiency. For example, one of the Ted Talk videos mentioned that 25 cent of every dollar spent on the economy goes to health care. However, from our group discussion we learned that very little of that money goes towards patient care. The health care system in the US has become such a complex conglomerate that most of the money goes to keeping the processes running. The second factor is lack of access to health care. When uninsured patients get sick, they seek treatment at the last minute. Rather than going to the doctor early to get the problem taken care, they wait and wait hoping that the medical problem will go away on its own. When they do present, the problem is now bigger and takes more money to treat. This was illustrated by the examples above. Patient #1 could have been treated with antibiotics without ever requiring surgery. Patient #2 just needed blood pressure medications, but now is stuck on life long dialysis

A/P: There is no doubt that there is a health care crisis in America and people even say that this system will bankrupt the country. From a physician’s point of view, the most important thing we can do is “catch” the sick patient’s at an early stage. This means that we must emphasize our screening examination. In addition, we can volunteer at the health care fairs where we can do free screening for diabetes, cholesterol and hypertension. Once we identify these people, we can refer them to free health clinics in the area. One example is Cass clinic. This will increase access to health care for the patient and decrease the potential morbidity of disease.

[James Bathe]

S: Lack of insurance. The almost uniquely American condition that kills and maims people but is not biological in nature. Rather, it is a decision by our society that health and health care are to be treated like commodities. Other developed countries realized long ago that having a national system of health care and providing for the health of all citizens is the most cost effective and best in terms of outcomes for patients. However, entire industries and economies are based on the idea that we have to pay in America. And, we already know how hard it is to face up to some medical conditions. If there is a financial barrier, we are far more likely to ignore medical conditions until it is too late. All in all, a commercial health care system like we have in America is harming patients and continuing to support it is continuing to support patient harm.

O: I tend to keep costs in mind while treating my patients. Coming from a backgound of poverty, every test cost, every prescription, every procedure is a HUGE deal on a budget. Plus, early cost effective measures are key to prevent those progressions to completely out of this world levels of costs

A: From my background, I am acutely aware of this issue. However, my experience on the cheapest options is limited. I’ve been asking for this information to be easier to find but it is hard to really get costs well represented for our prescriptions.

P: I plan on spending more time finding out the lowest cost option for various procedures and medications.

[Lea monday]

Social Determinants of Health #4 Reducing waste by limiting duplication of tests/imaging And group discussion

This weeks group discussion was the most useful for me. Our last group talk was about bias in healthcare which everyone said they did not do and people were not very open in the talk. However, this months talk was more productive and people were sharing their frustrations navigating the health care system. It was very interesting to hear from my coresidents from Canada, India, and pakistan about how things are different in those places.

We discussed how if it is hard for us to navigate, imagine how confusing it is for our patients. I used to think patients did not get tests or go to referrals because they didn’t want to or maybe their issue resolved, but it is more likely they have trouble navigating a confusing system.

We also talked about waste and the ted talks. I think our program does a good job of teaching us about resource utilization and minimizing waste. Dr weinberger and Levine often bring up the “choosing wisely” campaign on rounds and we have learned about that website as a resource. I think teaching us these aspects is a strength of our program

[Sahrish Ilyas]

Social Determinants of Health #4 Lack of basic healthcare

Lack of healthcare insurance certainly is a great obstacle in obtaining basic healthcare. Lack of health insurance also leads to many patients being diagnosed in later stages of disease. This is a recurring theme that I witness firsthand inpatient and in outpatient clinic. Many patients, now in their 40-50s, present to clinic with myriad of problems that had been unattended for so long due to the basic fact that they were previously uninsured and lacked access to basic healthcare (e.g BP checks). It may very well occur that they may present at a stage in their disease process with manifestations of end-organ damage such as hypertensive/diabetic retinopathy. This can easily occur as many chronic diseases are often “asymptomatic”.

As discussed in the module, there are many repercussions associated with insured status including decreased adherence to treatment due to fear of cost and frequent loss of follow up for the same reasons. Many patients at our clinic, despite being insured, also encounter these issues due to high copayments and forgo filling their necessary prescription medications or scheduling necessary appointments to see specialists.

Plan: i hope to find time to do some basic research on readily available resources in our community such as free health clinics, free prescription programs etc to better held our patient population maintain adherence to treatment plans.

[shanker kundumadam]

S : This week discussion was about how uninsured or not adequately insured status is actually a social determinant of health. I totally agree tot his. Quite often we see patient’s in miserable situation because of the same.

O : This clinic week I haven’t come across any situations like above. But a week prior to this in my floor month , I had a patient who had insurance and needed placement in a nursing home. He is a Veteran and family wanted him to be placed in the VA inhouse hospice facility. Hospice was denied to him and the only other option was to place him in a Nursing home. He has insurance and it would not have been an issue but the family was insisting he go to the VA hospice rather. On looking into
the matter more we realized the reason why family was hesitant for NH was because his pay check from the government will be
directed to the NH rather than the family. This case was interesting that despite having an insurance and money still this patient
due to the family dynamics was not able to get proper care and appropriate placement.

A/P
From a physicial perspective will try to be better informed about the costs involved in health care , tests we order and medications we prescribe. z

[Shahram]

Social Determinants of Health #4 Lack of basic healthcare and health care disparities related to socioeconomic status.

We discussed about the problems that our patients face due to issues related to insurance. I think the root cause of this is that we have a system in which we have contracted for profit companies to provide health insurance to people with very limited check and balance.
Basic health care is a right not a privilege.

What we can do: As discussed we should try out best to minimize the number of tests we order both as outpatient as well as inpatient and of the test were done in a outside facility try to obtain the records rather than ordering the tests again.

This week I had a couple of patients with similar problems and one of them was concerned that he might loose insurance, I prescribed him his medication for HTN and DM with a refill of 11 months and encouraged him to keep taking his medications even if he looses his insurance and he can still call in to our office and speak to us if there is any concerns, educated him how to monitor and adjust BP meds dose if needed.

[Harold Obiakor]

S: This week discussion was how lack of health coverage or inadequate health coverage affects the quality of health in our patient population. The discussion was centered on the need for basic medical coverage and how it impacts health of our patients compared with that of other developed countries like the US.

O: Considering the fact that health coverage will never been evenly distributed across our patient population, it is imperative to keep in mind the types of insurance available and what they are able to cover. Prescriptions should be carefully tailored to meet the insurance coverage of each patient.

A/P: Find out what insurance each patient has and determine what they are able to cover for each patient. Consult with the pharmacy when appropriate to ensure that each prescription will be covered by the patient’s insurance company.

[Muhammad Usama]

This week discussion gathered around basic insurance coverage and how lack of it significantly can affect the patients. Even when we have health insurance, due to lack of check and balances and complexity which has been created in understanding the billing and insurance coverage works is baffling. I recently saw two small informative videos on VOX.com which to some extent explained why is the Insurance coverage for healthcare cost is so complex. Even being a provider I understand it much better than the general population but still, I believe I do not understand it that well to answer patient’s questions. My wife was recently admitted to the hospital for childbirth and even after paying for top-tier health insurance package, I do not know how I got 3000$ bill because many charges are just marked facility charges with no actual description, which I plan to go not more depth to get a better understanding. I tried to calculate many times based on my insurance package what would be my estimated bill and made some calls but no one knows the answer even in the billing department of our hospital. The fact that insurance coverage is so uncertain, it prevents many patients to come see providers to seek medical care even for most urgent issues, because they don’t know what bill they would be getting. It makes it really uncomfortable for those who live paycheck to paycheck. Recently I got across an interesting article that now one new insurance policy expects patients to diagnose themselves before visiting the ER otherwise they wont pay their bill. These denials are made after patients visit the ER, sometimes based on the diagnosis after seeing a doctor, not on the symptoms that sent them. Which I believe if happens in our patient population, it would further grow the distrust of healthcare system in their minds and would prevent them from coming to see us for medical care After reflecting my personal goal is to do more effort to understand insurance system better so that to be well informed to guide the patients. As physicians, we should also lobby at different levels within our capacity to decrease healthcare costs. Ath the end I would request the readers to go through the following article and videos which enhanced my understanding of healthcare system

An ER visit, a $12,000 bill — and a health insurer that wouldn’t pay.
https://www.vox.com/policy-and-politics/2018/1/29/16906558/anthem-emergency-room-coverage-denials-inappropriate

The real reason American health care is so expensive

Giving birth costs a lot. Hospitals won’t tell you how much.

[Amina Pervaiz]

This week’s discussion was how lack of basic health care/health insurance affects the patient and the fact that they are not able to get the adequate treatment and are not able to keep up the referrals to the specialists. Understanding health care is very challenging and despite being working in the US health system for some years now, I am reluctant to say that I understand it completely.

I had 2 cases in this clinic week, which I would like to share and I beleive can have an important impact on pt care.
1. One of my pt was discharged from hospital for COPD Exacerbation and he was prescribed the inhaler which was not even covered by his insurance company and he didnt get that inhaler till he came to see me in the clinic and I called his pharmacy and asked about whatelse will be covered by his insurance. So, pt didnt have the inhaler for almost 2 weeks. I gave him a few samples from our clinic as well. I believe we need to be mindful of insurance coverage before prescribing the medications (we can call pharmacy or look up online pt’s insurance coverage) to avoid delay in the pt care.
2. A second instance, I prescribed the cream to the pt and she called me later and told me that she had high co pay and if I could order a generic/another formulations, which unfortunately was not possible, but by calling the insurance company, and filing out some forms we were able to reduce to the co pay which was acceptable for the pt.

Understanding the health care system completely is very difficult, but we can ensure that pt gets our prescribed medications by carefully reviewing the pt specific health insurance and coverage and can avoid delay in the pt care and subsequent hospitalizations from not being able to have access to adequate treatment.

[Jared Goldberg]

This week’s topic regarding health insurance in the United States is one that we often hear about in the news but hardly ever reflect upon in our day-to-day interactions with our patients. The United States is one of the last, if not the last, industrialized country to not provide universal health care for its citizens and residents. Despite what the politicians and the ideologues say, the main reason we still do not have is political, pure and simple. There are vested interests that would like us continue paying middle men to ration our health care. Yes, when you have tiered insurance plans with different levels of coverage based upon ever-increasing premiums, YOU (or rather the patient) will ration the care based upon cost. At least two of my patients this week had gone without medications because their insurance coverage had lapsed (and, even with the ACA, did not qualify for Medicaid). While I’m always hesitant to make my personal beliefs known in a work setting, this SD module doesn’t allow me to conceal my feelings: I participated in a universal health care workshop in Washington DC when I was a second year medical student. We educated ourselves on single payer and went to our congressmen and women to lobby for it. Many of the difficulties our patients face would be improved (but no necessarily solved) by universal health care. Health insurance, and either the lack thereof or under-insurance, is just as dangerous as many of the diseases we treat every day.

[John Dawdy]

S: The case/videos associated with this week offer a number of different topics that I think that we could focus discussion on. What I’m going to focus on is a line from the 2nd video discussing the ACA and problems with a healthcare economy. Particularly I’d like to focus on the idea that we are uninformed consumers of healthcare and take one step further in that we are very often uninformed providers of healthcare. Uncontrolled spending in healthcare is often attributed to redundancy, malpractice, and increasing consumer demands for the newest and shiniest care available, but I think an often overlooked aspect is that with all the burocracy in place within the healthcare field that we as providers do not know how to best help our patient navigate these monetary challenges and roadblocks placed in front of them. We often order a test/medication that we think is best and let somebody else worry about the cost and how the patient will pay for it. It is something that I am guilty of and I don’t think that I’ve seen a colleague that isn’t.

My patient experience this week was with an older woman new to our clinic. She was previously followed by a number of physicians within another health system in Detroit for over 40 years. However, when she was recently informed that her insurance no longer covers her previous physicians and she has had to transition to our office. I asked her if her insurance had changed, but it did not. I asked her why the change then. She reported that this year, like every other year her company gave her different options to choose from for insurance, in years past there were 3 options and she always picked the middle one, but this year there were 5 options, so she once again picked the middle option thinking they would be equivalent. This was not the case. When I asked her if she had read the details of the plans she said that she had, but she couldn’t understand how the differences would impact what doctors she could see.

But John, she’s older, she didn’t read the fine print or ask the right questions beforehand, its her fault. Although I didn’t hear this in this particular case, I’ve heard similar lines for similar instances, and don’t suspect that will change. I usually ask what if it happened to you or a family member and wouldn’t you want to know why it was so easy to make such a big change?

Although slightly different I think back to my own experience this past year. I had an imaging study completed knowing that it made sense diagnostically and expecting insurance to cover most of it based on my insurance plan. However 3 months later I got a bill saying that my insurance wouldn’t cover any of it. I wasn’t sure why that was and it took 5 months and dozens of phone calls to find out that the coding that was in the original office note did not justify the testing that was performed. I felt stuck at this point, unsure of what step to take next, and not having the time given the demands of residency to spend an appropriate amount of time to figure it out. In the end, I spent two weeks salary on this test, but I think about my patients that aren’t lucky enough to have that available to make this bill go away. If it’s this hard for somebody that works in the field to navigate and get answers, how hard is it for my patients? How can I make it easier?

O: It has been a goal of mine to better understand a number of aspects regarding health systems function over the past 6 months after my own experience. These include billing requirements and Medicare/Medicaid formularies. I make it a point to look up brand name medications when our EMR forces us to pick one to prescribe, and I plan to continue this moving forward.

A: The longer I practice the more aware I become just how little most physicians are aware of how the healthcare system works on a fine level. Whether it is knowing what medications are on formulary, how exactly to bill for certain items in order to get a medication or procedure covered, or the broad strokes of referrals inside/outside network, very few that I’ve worked with seem to have these mastered. Although I strive to have a better understanding than most, this is a work in progress, and with the seemingly ever-changing bars that are placed in front of physicians an uphill and time- consuming battle.

P: I plan to continue my above efforts to better understand our hospital system as I progress though my training. Although viewed as tedious and low priority at this early point in our training, I appreciate ambulatory lectures regarding these topics if presented properly and hope to see more in the coming months.

[Leslie Kao]

Poor or minimal access to healthcare is a major issue that we must grapple with not only as inner city healthcare workers but also personally as individuals on a limited budget. Post-ACA, we saw a huge increase in the number of people who have been insured. However, being insured is different from being appropriately or comfortably insured.

Regardless of the fact if the patient has insurance or not, most patients are one medical emergency away from financial ruin, which makes preventative care even more important than just from a pure medical perspective. The US is one of the only industrial countries that does not provide its citizens with universal coverage. Even with the ACA, our insurance market is made up of private companies that offer varying degrees of coverage for varying degrees of money. Along side the multitude of for-profit and non-profit hospital systems, we as physicians are unable to tell patients the final cost of a visit, imaging or a procedure. Many times this has prevented a patient of mine from seeking care earlier. Our healthcare system is now run by a mosaic of corporations with ceos that have no practical experience in healthcare. As physicians and patients, we have let control of our industry slip away from us. We are now cogs in a machine who’s primary beneficiary are not the customers or workers, but the investors. As physicians, we must take back control of our own industry so that our primary benefactors are our patients and their health.

[Kalyna Jakibchuk]

This is my second time posting on this forum, although the first was somehow deleted from the 21st, so I am going to try to reproduce my original thoughts after our great group discussion on Monday. Leslie, I don’t know if you can help figure out what went wrong with that.

S: Access to health care and insurance problems need to be addressed in the United States. This module made me reflect on the different health care systems in the world. The fact that there are so many different health care systems, none identical shows that it is difficult to create an ideal system and that each system has to be unique to its’ population. Unfortunately, the United States is one of the most developed countries in many ways but yet lags behind in its’ health care. I think that this needs to be addressed. Having lived in a country where there was socialized medicine, there is something positive to be said for basic health care coverage for all citizens. I think it would be an additional benefit if those who wanted to have other added benefits to pay extra. In the United States the problem is that there are many people who still can’t afford to pay for their basic health care and the expected literacy level to understand how to navigate through the system with insurance companies is too high. We all suffer when this is the case.

O: I constantly have patients that tell me either they don’t want a test done because they can’t afford it, they are not taking a medication because they can’t afford it or they never received the med because they were waiting for prior authorization. My personal experiences in the health care system also left me feeling defeated and frustrated with the costs and the complexities.

A: I admit that my understanding of the health care system in the United States is lacking. I myself, am trying to figure it out as a patient. As a provider I wish I had answers as to how to make it easier for my patients to get the medications and the care that they need. Not even some nurses that deal with insurance companies have the answers. I recognize that this creates frustration for myself and other staff.

P:Going forward, I will try to cut down costs for unnecessary things for my patients. I will continue to be part of organizations like the WCMMS so I can voice an opinion about these matters. I would like to find a way for citizens and physicians to make a change in the system.

[wsumed]

The Great Deception: Can the European Union Survive? by Christopher Booker — 9780826480149

[Author]

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