Hospital based internists treat many patients whose problems are frustrating because they are chronic and often incurable. So we “manage” a bundle of disease states and attempt to keep people functional in spite of their underlying progressive problems. In doing so we are always considering how we can improve our performance but our performance blends with how well the patients themselves perform. Their performance is linked to the social supports which are available to them. Medical insurance, its individual presence or absence, its real functionality in each individual case—the question of whether it actually offers a human an affordable means of obtaining medical care— is of course the most crucial support.
If in the United States if medical insurance plans or systems were languages they could be thought of as a tower of Babel. We have Medicare and its various parts(A,B, etc) and we have Medicare plans administered by insurance companies(a means of insuring that the insurers get a bite of profit from our taxes). We have Medicaid, which some states have refused to expand and which some states are trying to strangle. We have multiple private insurers that offer plans via employers and we have private insurance which individuals can purchase under the Affordable Care Act. Then there is the insurance plan that covers active military and uniformed service members, there is the VA system, the Indian Health Service…the list appears endless.
All insurances do different things. Some pay for a treatment that others do not, many include strict limitations on the clinicians the patient can see, no matter how far away those clinicians might be. Some require pre-certification for certain procedures, treatments, diagnostics or drug prescriptions, and it seems they all use different criteria to judge whether a patient is sick enough to be in a hospital. Attempting to practice medicine in such a system is crazy-making and is worthy of the work of Kafka.
For the patients it is worse. Some have such high co-pays and individual deductibles(a means of making an individual, in a sense, insure herself) that an individual will avoid medical encounters due to their potential financial “deductible” burden in spite of the notion that they have “health insurance.” These are a mass of people who appear to be insured but cannot really use the insurance because by the time they have paid the deductible they would be financially ruined.
Then we have of course, a huge mass of individuals who fall through all the cracks and simply cannot afford any kind of medical insurance.
I will not venture to discuss insurances for persons with mental illness, it would be too schizophrenogenic for me. For clinician readers who are curious about dental insurance, just look very closely into the mouths of most of your patients and reflect upon the inflammatory burden that so many of them are carrying around embedded in their mandibular and maxillary regions because they are unable to afford dental care.
This Babel of insurance support or lack thereof creates in a sense multiple medical economies. Thus we can perform one treatment for one patient but not the same for another. One patient can recuperate in a skilled facility, another with an identical picture cannot due to his/her insurer’s discretion on payment. One diabetic can get the highest quality insulin, another cannot due to differing pharmacy plans. Insurance plans flood the desks of primary care physicians with forms they must submit to get various test, imaging or pharmaceuticals “approved” for their patients. The inefficiencies of the current “system” are jaw-dropping. They repeatedly make what should be a fairly straight line from diagnosis to treatment turn into multiple circles of clerical insanity. The medical avoidance that persons with paltry insurance coverage (or none at all) exhibit ultimately places further burdens on all of us.
In the next blog I will present two patients I cared for simultaneously who were at opposite ends of the medical economic spectrum, one who used his insurance to radically and successfully change his medical status and one who practiced medical care avoidance.