I usually write about health care reform from a pediatrician's viewpoint, but what grabbed my attention recently was a story my husband, Randy, told me about an adult in his practice -- a patient on Medicaid.
Randy is a neurologist in a private practice and Medicaid patients come from every corner of Rhode Island to see him. They make this cumbersome pilgrimage because he is a member of a dying breed: Randy still accepts Medicaid. He does this for $27.
That is not a copay; that is the total per patient reimbursement he gets from the state. It is clearly not a good deal for Randy, who will start losing money about 10 minutes into the visit. And it is often not a good deal for his patients, who may have to travel a very circuitous route to receive simple, appropriate care. But it is also a terrible deal for taxpayers. The American taxpayer needs to understand how this Medicaid patient ended up in Randy's office.
Randy's patient was a slightly overweight, balding man who would hardly stand out in a crowd if it weren't for his obvious reliance on a medical escort to gently help him move about and answer questions. His speech was clear but simple, and he stayed on message: "My toe hurts." They had driven about 75 miles to deliver this message.
Randy spoke directly to his new patient, slowly teasing essential information out of a person whose most reliable verbal tools were "yes" and "no." This unhappy fellow had had a sore toe for several days and was trying not to bear weight on it. The only symptom the staff at his group home noticed was that he seemed to be losing his balance. One morning he was so distracted by the discomfort that he stumbled in the shower, causing a minor cut on the toe. They were not surprised to see that the injured toe was swollen and tender.
Medicaid, like every other public and private payment program in our fee for service (FFS) system is based on a model of productivity -- high patient volume -- rather than quality. Fee schedules provided by Rhode Island's Department of Human Services indicate that a primary doc could have expected a reimbursement of $20.50 if she saw this Medicaid patient in her office. Physicians who accept Medicaid often feel pressured to increase patient turnover by speed-reading records, keeping conversation to a minimum and quickly offering a prescription or tests.
If there is any reasonable way to put an "urgent" slant on the situation, the primary care doctor can completely avoid a money-losing office visit by referring the patient to an emergency room. In this case, "loss of balance, difficulty walking" provided the admission ticket for this patient to be referred directly to a local ER. From the primary doc's perspective, the underinsured patient will still get medical attention and the local hospital, rather than the doctor, will now be absorbing the cost.
It is the very nature of an urgent care setting to emphasize quick, decisive action over conversation -- especially with a patient who is slow of thought and speech. This man's ER encounter ($92 for the provider plus "institutional" fees for the hospital) consisted of little more than a hurried doctor considering the reason for referral and ordering a CT scan of the head ($156) to rule out an intracranial cause, like a stroke or tumor, for his loss of balance. With that test normal, the patient was referred to a neurologist to sort out the strange mystery of why he could not walk.
Two weeks later, sitting face to face with this man, Randy slowly, methodically pieced together this story; what it lacked in detail it more than made up for in focus: the quiet man who would not walk was not concerned that he was losing his balance or even that he fell in the shower. His toe just really hurt, and it had been hurting for what he felt was a very long time.
The records Randy received were flimsy, but he noticed that the patient was on allopurinol, a treatment for gout. As any first year medical student can tell you, gout is a very painful form of arthritis that is caused by high uric acid levels in the blood that deposit as crystals in the joint, causing pain that has been described as a fiery volcano in the ... you guessed it.
The most common site of gouty arthritis is the big toe. Randy stooped to help the wincing patient off with his tennis shoe and tube sock. There, where a normal toe should have been, was a swollen, angry Mt. Vesuvius.
A flare-up of gout should have been promptly managed by a properly reimbursed primary care physician. Instead, the total cost erupted as steadily as the condition and included three weeks of unnecessary pain, a whopping dose of radiation and expensive medical encounters that accomplished nothing. Finally, there is the cost that is at the heart of the taxpayer's problem: the cost to Randy that the $27 did not cover. This unfunded cost is what drives the expensive game of medical hot potato we play with underinsured patients.
Our current FFS system, which rewards productivity, tests and procedures rather than quality, is wasteful and ineffective at every step for all patients, but is particularly harsh for Medicaid patients. We have to move out of our narrow FFS mindset to appreciate what other models of care -- like medical homes and federally funded community health centers -- have to offer. We -- the sweet, slow-thinking man with the fat toe, the new mother with lots of questions, the frail, worried senior with a handbag full of medications, the overweight child, the conscientious physician, the small business owner, and yes, the U.S. taxpayer -- desperately need a smarter, more cost-effective healthcare system. Simply cutting programs like Medicaid is like putting a Band-Aid on a gouty toe.
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