Disgust

Truth be told, I felt disgusted with myself today.

I saw Mr. L back for review of labs. I saw him a few weeks ago for evaluation of gynecomastia (that's man-boobs, for you non-medical folks) from hypogonadism. I had reviewed his referring doctor's notes, some test results and an MRI scan of the pituitary. I had ordered a few other tests.

Anyways, he was a jovial, if slightly embarassed, 20-year old. He also had no medical insurance. And he mentioned that he got a bill for $850 for my consult and that he was arranging for financing.

I was shocked. Shocked by that amount. But also, shocked and mad at this country's state of medical affairs.

True, I provided the care he deserved, and I billed according to the level of complexity involved. From the physician side of things, that's about it- I don't get to decide how much to charge him, I don't get to decide how much out-of-pocket a patient pays (that's all regulated by some higher power, presumably the feds). Almost all my patients have insurance, so they pay only a small copay. Unfortunately, this man had no such thing, and bore the entire brunt of the medical bill.

So when I saw him back today, I did what I was told not to do; coded the visit with the lowest possible code, something equivalent to a nurse visit.
A few months ago I had asked my supervisor: I had been told it is not up to me whether I can no-charge a patient, even if they have financial difficulties. That simply opens up too many doors for risk of patient discrimination; i.e. why did I give free treatment to one patient and not another.

But it did get me mad thinking- is this how much a patient has to pay out of pocket to see a subspecialist if he doesn't carry any insurance? What are things coming to? Why IS healthcare so expensive? To feed us, the greedy doctors? To pay for the freebies the pharma reps throw at us? To pay for malpractice insurance to protect against unreasonable lawsuits? R & D?

I'm not sure I have the solution to this problem either. People here ask why the US can't adopt the socialist health system of Canada. I recall how some patients had to wait months just to get an MRI for an elective surgical procedure. Ditto for Malaysia- the poor still get healthcare, but at the cost of convenience, time, and arguably, quality (of meds, infrastructure, not doctors).

Somehow the simple code of the doctor treating the patient has gotten way too complicated. You see it in how we do all kinds of scans and tests 'just to make sure' (don't want to miss something and get sued later). You see it in the TV ads looking for patients to join the law firms in a class-action suit against a medication that has saved countless lives but undoubtedly had some side effects. You see it in cities which no longer have obstetricians, because the cost of malpractice insurance is simply too high (some places cost more than a new Ferrari F430 every other year). You see it in clinics that no longer give out free samples to the 99% of patients who need it, for fear of the 1% with ulterior motives who may use that against you.

In that regard, I miss the days when I saw patients at the Salvation Army free clinic. It was simple healthcare, repaid with nothing more than a $5 donation if the patient could afford it, or a handshake if the patient couldn't. I wish I had the time and energy to get back into volunteering.

Yes, I do feel disgusted with myself today.