Smog at the Economic Level

September 27, 2017

A piece of black humor I hear often uttered regarding patient satisfaction surveys is the hope that the patient survey does not arrive at the same time the hospital bills start to appear.

Humor thrives on recognition and examination of the absurd.  Who has not received a medical bill that appears absurd? A page filled with descriptions and explanations are all quite mysterious, even to physicians.  We puzzle over pages listing inscrutable procedures, descriptions of co-pays, explanations of family and individual deductibles, cost of procedures, insurance adjusted price, amount billed to insurance company(but  awaiting final determination).

The standard hospital bill delivers complexity upon complexity, to say nothing of various errors that can occur.  Once it took almost a year to convince a local hospital that the reason my insurance company was not compensating them for my wife’s major procedure was because they were billing it incorrectly with a cosmetic procedure code.  Actually, it was my office manager who spent hours on the phone, month after month, until someone on the other end awakened from a computer screen induced stupor and billed the event correctly.

Our American medical care “system” has become rife with what some economists call “economic pollution.”  The insurance realities for almost everyone change quickly as employers switch carriers to save costs.  Insurance carriers amend rules incessantly as they alter costs and benefits to maintain profit.  Individuals who purchase their own insurance jump from plan to plan  as costs go up. There are so many variables and pitfalls that the entire system is burdened with clerical costs that consume massive amounts of time and money. The confusion inherent in the system makes the analogy to smog warranted.  One can hardly see the economy of the process for the smog of changing and flummoxing economic rules that enshroud it.

For practitioners it means massive costs in overhead and hiring staff that can work to collect fees from the various entities that insure us.  For many patients who have insurance the system is so complex that they cannot comprehend it.

Sadly, for many insured patients, the one thing they do comprehend is how precarious they are in terms of health insurance.  If they lose a job, they lose insurance and perhaps a chronically ill spouse dependent on that insurance will go without medical care.  Or they know that even though they are insured, they really cannot go to a doctor because the deductible portion of their coverage is something that would financially drown them. Frequently we meet patients who are insured but cannot afford the prescribed medications, such as the best inhaled bronchodilators or most advanced insulins. Medicaid is now available in many states to people with very modest incomes, not available in others.  The system is labyrinthine and laden with economic smog. A large percentage of patients with Medicare are in “managed care” plans administered by the insurance giants, changing the rules frequently and always seem to be merely government-sanctioned middle men extracting a rent from the system.  We have all dealt with the wrenches they can throw into care plans to maintain their profit margins.

One of the very important skills in patient communication is the art of dealing with patient anxiety and fear.  When that fear is economic, how do we deal with it?  Recently I worked with a patient hospitalized for acute manifestations of what appeared to be chronic conditions of which he had been totally unaware.  He was eligible for Medicare, his wife was not.  She had chronic medical problems which were covered by his employer’s insurance.  As I tried to explain his conditions he warned me that he could not stay in the hospital for fear of losing his employment, thus losing the insurance he depended upon to care for his wife.  He assured me he could not afford to purchase insurance for her as an individual.

Thus his anxiety was something of a cascade, moving from economic insecurity to personal anxiety regarding his diagnoses and his job, to spousal and familial anxiety regarding the care of his spouse.  How do I communicate with him regarding that?

First I think it is crucial not to deny that the anxiety is real and understandable.  To admonish him for not focusing on his own well-being, to assure him that “something could be worked out” or to shame him for not addressing his own medical problems before they became so acute would not be in any way helpful or therapeutic.  Acknowledgment that he had a situation that would make anyone worried and anxious would be truthful and empathic.  Saying something like, “I see you have a real dilemma facing you at this point that would make anyone worried” would be a good start to exploring what his options might be.  The next step might be to assure him that we, the hospital, would try to help him sort out his options regarding insurance, putting a consult and call to the social worker who could help him understand what might happen to him and his wife if he lost time from work, lost his job or became disabled.

There may be no happy ending to these troubles.  The fortunes of many of our patients are dashed upon the rocks by the smoggy winds of the “system.”  It is foolish to to deny that financial anxiety is a vicious partner to the other anxieties our patients face..  Sometimes getting that anxiety out onto the table and being  empathetic about it is the best we can do to help our patients along their journeys.