Monday, May 7, 2012

Side Effects May Include Financial Ruin

Christopher Moriates, MD is a senior resident in Internal Medicine at the University of California San Francisco (UCSF). He is a co-creator of a cost awareness curriculum for residents at UCSF and is currently working with the American College of Physicians (ACP) on their national “High Value, Cost Conscious Care” curriculum. 

He winced in a way that made me feel his discomfort. It wasn’t overly dramatic; it was a response of a man trying to put on a brave face and hide his pain, but - as I gently laid my hands on his belly - failing against his best efforts. This man had real abdominal pain, the kind that is impossible not to immediately empathize with. I got concerned.

“How long has this been going on?” I asked, while my mind began to immediately tick through a differential diagnosis.

“Well it probably started a year ago, but got really bad about four months ago,” this otherwise healthy-appearing, thirty-something-year-old man said.

We were in a small curtained-off area in the hectic Emergency Department at San Francisco General Hospital (SFGH). I started to wonder what in the world would possibly cause somebody to wait many months with severe abdominal pain and rectal bleeding before coming to see a doctor.

I asked a few more questions, verifying that he was indeed having bright red blood with his bowel movements, had lost at least 10-pounds over the last few months and has dealt with nausea and debilitating abdominal pain ever since the end of last year.

So, I pulled out one of my most tried-and-true questions that I have picked up during residency:
“What made you come to the hospital today as opposed to yesterday or last week?”

The answer should have surprised me.

“Well, I didn’t want to see a doctor because I couldn’t pay for it. I had to wait until my benefits kicked in so that I had insurance.”

The Emergency Department had already put him through the CT scanner prior to calling me to admit him to the hospital, in order to ensure that he “didn’t have something really bad going on,” which I have to admit that if you had put your hands on his abdomen you would probably think was a more reasonable (if not very eloquently phrased) concern. 

The CT scan showed inflammation of his colon in a pattern that the radiologist said was very likely Crohn’s Disease.

His lab tests returned with severe anemia (hemoglobin of less than seven) and an undetectable iron level, revealing that the bleeding had been going on for a long time. I told him that I thought he needed a blood transfusion and a colonoscopy procedure in the morning by one of our gastroenterologists.

Then he asked me one of my most feared questions that I have picked up during residency:
“But how much will that all cost and will my insurance pay for it?”
“I wish that I could answer that for you, but I really don’t know.”

Now, the thing is that I actually have spent more than the past year working on cost awareness for residents and looking into issues related to costs of care, and even I couldn’t answer this question in a straightforward and truthful manner. This man needed these things done and costs be damned. Sure, but let’s be honest, his concern is very real. Medical bills are the leading cause for personal bankruptcy in the United States. And at his young age, the effects of an expensive inpatient work-up could be devastating for a long time to come. Incredibly, in 2007, 78% of filers of personal bankruptcy caused by medical problems had medical insurance at the start of their illness.

The best I was able to do was tell him that in my medical opinion he needed these procedures in order to make the diagnosis and get the right treatment for his disease. My medical training has taught me how to recognize inflammatory bowel disease, diagnose it and treat it, but it has not adequately addressed how to not inflict insurmountable financial harm on some of my patients in the process. To me, it is straightforward; this man needs medical treatment for Crohn’s Disease. To him though I may be replacing his abdominal pain with another debilitating problem.

This all seems especially unfair when just a few weeks ago we reviewed a case in our monthly UCSF Cost Awareness conference of an elderly man with a headache who was seen at our University-affiliated clinic across town from SFGH and underwent BOTH a negative head CT and a brain MRI and didn’t pay a dime – the outpatient MRI was “charged” on his bill at $3,644, of which Medicare paid the incredibly reduced “price” of $275 and Medi-cal picked up the $178 that the patient would have been responsible for.

The man’s headache, by the way, resolved with “meditation.” That’s probably a good prescription for all of us right now.


  1. The stat saying the 78% who filed for personal bankruptcy had medical insurance is disturbing, to say the least.

    I 'learned my lesson' when I was between jobs/starting a new job and failed to look into purchasing private insurance for the couple months before my new job's coverage would kick in. "Nothing'll happen, never has, I'm young and healthy." Probably the typical thought process for most in similar situations?

    Little did I know a couple weeks after departing my previous job I'd be hit with debilitating abdominal pain. I chose to suffer-- lying in bed or forcing myself to get up and go to work (still suffering) because I felt I could not afford to seek medical attention without insurance.

    Finally, I did go to the ER, the same day a letter arrived announcing the start of my new coverage, in approximately a week. I naively thought the ER staff could assist with somehow 'discounting' my visit as I needed to see a doctor and was practically on-board with them already. The desk staff were firm that I would not be covered and would pay the full rate, whatever it turned out to be. Desperate, I saw the doctor anyway. He palpated a little and informed me he could call the tech who does the ultrasounds but it was his day off. There was a subtle implication that it would be a bother and also probably expensive. When I declined, not really knowing what was actually being recommended, he quickly diagnosed IBS and suggested I see my primary care doctor if the symptoms persisted. I walked out still doubled in pain and somewhat deliriously confused. The ER bill followed promptly: about $1,500.

    Once my new insurance did begin, I selected a primary care doctor and went in to see her as soon as possible. Based on my severe pain, she had me do a CT scan, which found something indescribably worse than IBS and sent me on a medical 'journey' that I would never have guessed could happen to me.

    Thankfully, I'm doing well today. But I know for a fact the only reason I was able to receive and afford the medical care I needed (to stay alive) was because I did eventually have insurance through my employer.

    On a closing note, I'd like to add I am a young worker. I am not on Medicare/Medicaid, nor do I receive Social Security or any other monies provided by taxpayers or charities. Ever since I landed my first full-time job, I have paid for 'High' medical coverage. I do not ever expect 'free' healthcare. Speaking as someone who is more than willing to pay my own way, I hope everyone-- insurors, doctors, techs/nurses, consumers-- soon come to accept the current system is simply unsustainable. The trick is agreeing to the necessary fixes.

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  3. This is an accurate article. I too have had to decide between suffering medically or financially. Unfortunately financial has won this round. I just don't understand why some doctors need to read a study about this to "get" it.