Feb gets political!

So, how long did I get to do my job practicing hospital medicine before I had to argue with someone about finances?

Nine days. And what's weird was, I wasn't fighting with the party I assumed I would be.

We discharged a guy from the hospital last week, and because he'd had an unexpected event happen (I'm being intentionally vague about the specifics, but it's in that category of "maybe you can predict who's at higher risk, but you never know for sure if or when it'll get you"), he had to be discharged on a medication that was new for him. It greatly lowers the chances of future badness, but the med itself isn't exactly a glass of warm milk. You need to watch people carefully at first, test some blood, make sure the level is right. If it's wrong, things can go very bad indeed. This requires careful follow-up with the primary provider.

So I'm calling Scheduling to make sure this guy can a) get the appropriate blood test in a few days, and b) get in to see his regular doctor pretty soon. The scheduler says, "huh, that's odd" and "I'm sorry, but I'll have to have you speak with so-and-so." Then I find myself on the phone with someone who says the patient can't be allowed to schedule these future appointments, because he owes our practice group over $2000. I'm speaking not to some insurance company, but to our collections person.

Turns out, the guy had tried to schedule an appointment a few weeks back, and was told he couldn't, unless he paid some portion of his outstanding bill. Again trying to be as polite as I could, I wondered out loud if maybe this unexpected nasty thing that caused him to be hospitalized for three days maybe could have been avoided if he'd, oh, maybe seen his doctor a few weeks ago. The collections person was not impressed. Fair enough.

But this person's heart was not made of stone, and when I mentioned that the patient, sent out into the world blindly with no assistance beyond me wishing real hard for their med level to be correct, could potentially die, they did relent, and allow for one visit, for both the blood test and the primary care check-in. But no more!

From now on, when I discuss how messed up health care is in our country, I will tell this story. It's personal, it makes me crazy, and I can see several sides of it, all of which are totally and utterly, for lack of a better word, fucked. In my mind, it all boils down to a few key things:

1) Sure, this dude smoked, drank, and ate cheeseburgers; in short, acted like most Americans do. Sure, if he'd been jogging, avoiding high fructose corn syrup, cigarettes, and other vices; if he'd been eating bran muffins and celery sticks instead, he'd be better off now. But we play the hands we're dealt, and the guy in front of me is this guy, with this history. I have to treat him, not the version of him I would prefer to see.

2) According to what I could tell, he has insurance. I know a former Blue Cross claims agent who pointed out that lots of people have "80/20" plans, where the insurance only covers 80% of anything. That fits with the amount between $2000 and $3000. And of course, that bill is about to go up, from this recent hospitalization.

3) We're a private clinic group, so my own salary quite literally depends on the collections person doing their job, and doing it well. This person is, and I have no ilusions about this, on my side. God knows how many situations like this I'll encounter in my first year. If, hypothetically, my bleeding heart insisted on enough people in this situation being given care anyway, and if enough of them were unable to pay, then eventually we'd collapse and be able to help nobody at all.

4) And yet, when it all comes right down to it, I am not willing or prepared to say "screw this guy." I won't let him go out and die, or (worse for the system) get sicker and rack up more costs, just because he can't get in to see somebody. There are free clinics, but not enough, and anyway he earns too much at his job to qualify. There are a handful of sliding-scale clinics, but they have a waiting list that's months long, and he needs to be seen in a week. The walk-in urgent care centers don't do the ongoing primary care stuff, and the ER can do any test you want but it's ten times the cost so that's no solution.

And while it makes good sense in several different ways for my respected colleague the collections manager to aggressively defend the solvency of our business, how much would we have to pay his family in the event something bad happened and someone made a convincing argument that we could have done something to prevent it? (Ahh, but you can't reliably measure potential costs, and health care is all about potential expenses vs potential savings. Ask anyone who works in primary care why they don't make more money, and that's essentially the answer.)

So, for me, that's what the debate about a public option boils down to: somebody has to be willing to look that guy in the eyes and say "no." No, you can't get treated. No, you don't deserve a slice of these limited, expensive resources. No, the situation you are in, when stacked up against the situation others are in, and compared to what we have to work with, does not warrant you having this test, this visit, this intervention. And by the way, no, there is no reliable, consistent safety net we can allow you to fall into, so that at least there is a minimum standard you can count on. Have a nice day.

Because here's the thing: we say no to people all the time. We ration health care in the United States. We just like to pretend that we don't. And it doesn't go to the sickest first. In my opinion, getting anywhere near that truth freaks people out.

Well, the next person I encounter who doesn't believe in reform, or thinks a public option is Communist, is going to hear this story. And then I'm going to tell them I'm not willing to be that person who says "no, there's nothing, now get out." And then I'm going to ask point-blank if they would be willing.