Wall Street Journal

When Patient Calls at Year's End,
So Do the Ills of the Health System
November 27, 2007

The end of the year brings a flurry of activity to the doctor's office.

Retailers have the Friday-after-Thanksgiving sales rush. My office has a rush of patients struggling with the dysfunctional health-care system.

We're trying to help everyone before the new year rolls around, when deductibles are reset, new plans are chosen and the prices go up.

We didn't design this patchwork system with perverse incentives and disincentives to care, but we're dealing with it.

My 22-year-old patient is having pelvic pain from endometriosis and will probably need pelvic surgery. She would like to have her surgery before her $1,500 deductible resets but she can't get into the endometriosis specialist until mid-January. My nurse called and tried to get her worked in, but no luck. We'll try to call next week to see if there's been a cancellation.

I had better luck recently removing a fatty lump from a 20 year old man's arm.  He was changing insurance at the end of the year and the lump was a small pre-existing condition on his "pre-existing" arm. It wasn't bothering him at the time but we figured his new insurance wouldn't cover its removal in the future if the lump became a problem. We took it off on short notice before his coverage switched.

Some patients can't beat the end-of-the-year clock. My elderly patient with congestive heart failure is in the so-called donut-hole part of her Medicare prescription plan, when her coverage lapses and she won't be able to afford her medication again until the New Year begins.

Recently, unable to afford her medication refills, she was hospitalized for fluid retention and severe shortness of breath after stopping her diuretics. So Medicare traded a convoluted end-of-the-year cost sharing provision for a $10,000 hospitalization. The prescription-drug program makes a profit, but Medicare takes the fall because of the gaps in coverage caused by an end of the year cost shift to the patient.

As the year closes out, I'm also seeing more self-insured patients with chronic diseases avoiding care.

A patient in his 30s has asthma and allergies that have been acting up. He could really use a flu shot, a pneumonia vaccine and a breathing test called spirometry to help us better manage his asthma. 

I haven't seen him since last fall but he wants medications refilled for a year without a check-up and without being seen. He's been healthy enough to avoid the doctor or the hospital this year and is trying to make it to the end of the year. He tried the same thing last year.

He's avoiding the preventive care and advice that would lower his risk of hospitalization because of the deductible costs and lost income from work to come to the office.

My patient with chronic kidney disease has put off seeing his nephrologist for five years because he has a $5,000 deductible and he's self-employed. His personal health insurance premiums are more than $12,000 a year despite his high deductible. I want him to come in for control of his blood pressure every six months. He usually stretches it to 12 months. 

He's debated dropping the insurance and just paying for the kidney transplant that he'll probably need in the next five to 10 years, but the company already has years of his premium dollars and he would be uninsurable by anyone else.  So far he's made it eight years and counting with the blood pressure and cholesterol medication I refill for him once a year. We'd have better chances delaying the transplant even further if his insurance helped him out more on preventive coverage.

Another patient will start the new year uninsured. She transitioned from the workplace to being a stay at home mom during her third pregnancy. She missed the deadline to apply for Cobra coverage but she couldn't afford the Cobra coverage anyway.  

The private plans she contacted wouldn't accept her because she was pregnant.  Although her husband is self-employed and could afford private insurance, she is uninsurable because of a normal pregnancy. Her most viable option at this point is to apply for Medicaid. She might have to declare that she's separated from her husband to get it, but I've seen people do that before.

Experiences like this will drive soccer moms to vote for nationalized health care. People who don't favor an expansion of socialized medicine should convince the insurance industry to figure out how to meet people's needs without driving people to avoid preventive care and play beat-the-clock. 

To improve medical care in this country we need to close the gaps in coverage so that private insurance and the public don't have to play shell games to cover the basics liking having a baby and treating chronic diseases like asthma and kidney failure.