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Tuesday, August 16, 2011

On American Healthcare Crises

A woman suffers from peripheral artery disease. She knows something is wrong with her left foot and is checked into a hospital. By how and why she is checked into the hospital that she is, is not known. It’s discovered that the low blood flow to her feet has caused need for some digits to be amputated. As part of diagnostical prerequisite, necessity, or whatever you want to call it, a mass in her lung is also discovered. It’s malignant and has metastasized (cancer with ‘mets’ = spreading). She is 55 years old, lives alone, and has family who live out of state. For all intents and purposes the patient is alone in the city and state she currently calls home.

She has worked her entire life but was recently laid off from her job, subsequently losing her health insurance. Luckily for her she collects about $1,000 a month in unemployment benefits; this has allowed her to maintain her home and a small quality of life.

The unemployment the patient collects renders her ‘over assets’ and ineligible for the state and national medical programs (AKA: Medicaid). And, the hospital she is currently checked into is out of her county of residence. This is a big deal for a patient who has no insurance. In many major cities ‘county’ hospitals exist in order to act as a safety net for provision of medical and psychiatric needs for all of their ‘county’ residents, regardless of things like ability to pay or legal U.S. status. In other words if you are an illegal immigrant, have no insurance, are dirt poor, and live in that county…you WILL be treated to the fullest extent (this varies from state to state, etc.). There is a dignity factor that plays into this hospital philosophy. For this patient, however, a large gray line is produced by which she falls into.

The patient’s toes are amputated, at no cost to the pt. This is an issue, medically and politically, identified as an emergent need; life threatening and easily fixed in the acute setting. Unfortunately for her, her cancer is not. She is stage 4 and requires chemotherapy and possibly radiation. These treatments are expensive, and could have an indefinite timeline. They also require a lot of follow up care in an out-patient setting, such as primary care needs, specialists, tests, labs, medication, and other treatments (let’s face it, without insurance even the wealthiest cannot afford this kind of medical care). And, because ethically speaking a patient cannot be left dangling, all of this care, cost included, will be the responsibility of the hospital system that starts the care in the first place.

If only the patient had been taken to her county of residence’s hospital she may be eligible to receive the care she needs to fight her illness. But she wasn’t. Despite all efforts on the parts of the physicians and social workers currently treating this patient, her county’s hospital declines to accept a transfer of this patient. Why should they? This patient is expensive. And, currently she is being well cared for at another hospital. Regrettably, (and I cannot stress the regret enough) her current hospital cannot begin or provide the treatment needed for her cancer because this is not identified as an emergent need. “This can be treated in an out-patient setting…” The patient’s only option is to remain in the hospital until her symptoms are managed enough for her to safely return home. The current hospital is under no obligation, and is philosophically critical of, providing on-going care to out of county patients. This has nothing to do with the will or desire to care for this patient, but everything to do with the funding.

Every hospital has the opportunity to receive funds from the state to treat uninsured patients whom are unable to pay for their care. All county and most non-profit hospitals do receive these funds. Of course these funds are capitated… meaning, that there is a limit to the amount of money the state will provide the hospital, but no limit to how much treatment the hospitals are expected to give (or how many patients land on the hospitals’ door steps). The difference = millions of dollars. Ultimately, some hospitals are more willing to continue to provide care in these situations than others. So, patients come from far and wide to the locations known for providing the treatment needed, leaving some hospitals saturated with expensive patients whom they will not be paid for. When other hospitals are asked to take these patients back, there, again, is no obligation to accommodate.

Meanwhile our patient is stabilized, discharged home, and days later she is re-admitted to the same out of county hospital. Her illness is progressing and causing more symptoms. Again, the current hospital will treat the patient’s acute, or immediate needs. She will then be discharged home, again, in hopes of eventually accessing in county care. But, because this hospital cannot logistically, realistically, or feasibly keep its doors open if it takes on the responsibility of the entire state’s uninsured population, it cannot provide possible life sustaining/saving treatment to this patient. We must “share the wealth…”

In all things, it is the patient that ultimately suffers here. She will continue to get sicker and sicker. The patient WILL lose her life to cancer. Even with treatment she may only gain one extra year of life. The injustice in this is that this patient is not allowed the same fighting chance that you or I would be, OR of a wealthier, better insured person. Understandably cancer is a horribly hopeless diagnosis; but a cancer diagnosis for this patient means even less hope.

Who then takes responsibility for this patient’s life?

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