By Manoj Jain
Special to The Washington Post
Tuesday, October 14, 2008
When I walked into the hospital room of a 19-year-old woman, a foul smell all but overwhelmed me. I called a nurse to assist me and saw her, too, catch her breath.
When we examined the young woman we found a chronic infection of her pelvis so painful that she resisted our slightest touch.
How long had she been living like this, I wanted to know. Through tears, my patient hesitantly began an explanation that told me as much about our diseased medical system as about her illness: She'd had diabetes since she was a child, she said. On her 18th birthday, she lost her insurance and had been able to afford insulin only occasionally. She worked two jobs, she said, but neither offered insurance. Uncontrolled, her diabetes had let the infection develop and fester.
As I left her room, I realized I'd already grown accustomed to the rank odor. That, I think, is what happens when we learn that 47 million people in the United States are uninsured. At first, we find it shocking. But over time, most of us learn to ignore it.What's in Your Wallet?
That experience sparked a conversation with a friend, a primary care physician who told me that about 20 percent of the patients he treats at the hospital are uninsured, and he is not compensated for treating them. (As physicians sometimes say, "No other professionals -- lawyers, plumbers, accountants -- provide uncompensated service to one-fifth of their clients.")
Although the uninsured look like any other patients, it's easy to spot them: Their charts have places for their address, emergency contact and insurance information; an empty insurance box is a telltale sign. Some doctors examine this sheet before examining the patient -- a practice we refer to as a wallet biopsy.
The 1986 Emergency Medical Treatment and Active Labor Act declares that hospitals cannot refuse care to critically ill patients and that the physician on call must treat them. Internists with privileges at a hospital (like my friend) are usually part of the on-call rotation for the emergency room.
"I used to get angry every time the emergency room admitted an uninsured patient," he said. "I would try to spend less time with them -- 20 minutes instead of 30 -- and try to get them out of the hospital quickly and hope they would not come to my clinic."
It's not uncommon for patients with no insurance or poor insurance to receive different treatment. A 2006 study of 25 primary care private practices in the Washington area showed that in nearly one in four encounters, physicians reported adjusting their clinical management based on a patient's insurance status; nearly 90 percent of physicians admitted to making such adjustments. For patients with no insurance, alterations occurred 43 percent of the time; and for the privately insured, just 19 percent.
Some of these adjustments make little difference: Uninsured patients received more generic drugs and multiple drugs. A doctor might prescribe two generic pills for high blood pressure -- an ACE inhibitor and a diuretic, which together would cost $20 for a given period -- instead of a combined brand-name pill, which would cost $241.
The impact of other decisions is more worrying. A heart surgeon told me he operates on uninsured patients but schedules them for the end of the day; if other cases take longer than expected, the uninsured get bumped. Some gastroenterologists are quick to perform endoscopies or colonoscopies on insured patients; not so for the uninsured.
Some uninsured patients forgo tests or treatment. According to a 2003 study, participation in screening tests for breast cancer, prostate cancer or high cholesterol was 30 percentage points higher in some instances among people with insurance than among those without. Once the uninsured become eligible for Medicare, that gap shrinks.
Although the uninsured can be guaranteed care by coming to an emergency room, not all care is available there. Nor should it be. Estimates suggest that an ER visit is six times more expensive than a clinic visit.
Take the story I heard of an uninsured 31-year-old man who came to the emergency room complaining of pain in his groin. A CT scan revealed enlarged lymph nodes and what looked like a tumor above his left kidney. This was not the kind of problem that the ER would take care of; nor was the patient so ill that he required admission. So the ER doctor referred the patient to the urologist on call for a follow-up office visit.
The patient never went. A year and a half later, he showed up in the ER, with worse pain. The tumor had spread to his testicles, which were surgically removed a couple of months ago. A new urologist discovered that the patient had an endocrine tumor, which could have been managed with medication.
That patient's experience is reflected in research. A 2007 study by the American Cancer Society showed that patients with no insurance have lower survival rates for breast and colorectal cancer than insured patients. Similarly, a 2004 report in Health Affairs showed that people ages 51 to 61 with diabetes, hypertension or heart disease had a mortality rate of 12.5 percent over eight years if they had insurance and 18.8 percent if they had no insurance.
There may be a few among the uninsured who prefer to buy $149.99 sneakers than health insurance. Far more common are stories of preexisting conditions that make insurance unaffordable or jobs that offer none. My primary care friend told me about a patient who had left a boil untreated until it needed surgical drainage and intravenous antibiotics. When asked why didn't have insurance, the man said he had lost his job and was recently divorced. Stories like that helped my friend realize what injustices the uninsured face.Makeshift Solutions
At the hospital, I avoid looking upfront at the patient's insurance status. In my office, my receptionist asks uninsured patients to bring a deposit of $50 to $75 and offers a payment plan. Some surgeons expect a $500 down payment before an operation.
I do not discriminate at an individual level, but many doctors, including myself, discriminate more broadly by moving our clinics to wealthier parts of the city, for example. To compensate for the cost of treating uninsured patients (about 10 percent of my practice), I inflate my charges for all patients, thus increasing my income from commercial insurance. According to a Kaiser Commission report, uncompensated care for the uninsured cost $41 billion in 2004 , the majority of which was paid by the government.
In my city, Memphis, as in many other cities, doctors are applying their own makeshift bandages to our hemorrhaging system often in collaboration with faith-based institutions. One Memphis doctor -- who is also a Methodist minister -- founded the Church Health Center, which cares for more than 50,000 patients. The city's Muslim community has a clinic alongside the mosque where my partner volunteers. At the Hindu temple clinic where my wife and I volunteer, I counsel patients on vaccines and infections.
And as that foul odor wafts through my consciousness, I advise them on how they should try to get health insurance.