Monday, August 22, 2016

The R word revisited

As I was browsing social media, I saw a blog written by an American doctor who had to take a cousin to a National Health Service (NHS) in Britain ( She reports that he cousin's ankle injury was evaluated and treated in 4 hours. There was no copay. The patient only had to give her name and birthdate. Overall, the report is positive about the NHS.

A friend was visiting Germany, when her daughter had a minor eye injury. Within about 4 hours, on a weekend, the child was seen and evaluated by a the emergency physician, who called a pediatric ophthalmologist. A few years later, the same child had a head injury on a trip to Austria. Again, positive experiences with minimal if any copays.

Yet, here in the US, I just mailed billing sheets for my son's treatment. Again. They had to be revised, since the insurance company wanted things written up differently. And, I know that, since I haven't yet made the yearly deductible, I won't be reimbursed for his treatment by an "out of network" physician. As I was preparing to send these bills in, I noticed that the yearly "maximum out of pocket" has again increased, now to $25,000 for the family.

Earlier this month, I had a $2,000 copay for a minor surgery, which was collected in advance. If I hadn't been able to pay, the surgery would have been delayed or cancelled. Earlier this year, I had to pay a similar amount for a PET-CT.

I'm fortunate, in that I am again in good health, and able to return to work. I also had adequate savings, but, these kind of charges are a challenge for many people, even middle class people with insurance. As a result, care may be delayed. Sometimes, the problem will resolve as people work to come up with the estimated copays. Sometimes, it will get worse. As physicians, we work to sift out those who will resolve, and not subject them to expensive procedures. Often we are right. But, not always. And, so sometimes the problem worsens.

In July, we had a patient scheduled for a surgery for what was thought to be a slow growing cancer. She had some delay due to the preapproval process. By the time of surgery, only a few days after I had met her, another scan showed a marked increase in the size of her tumor. Hence, the plan for treatment had to be changed significantly.

These copays and "maximum out of pocket" expenses are a major limit in health care. It is a reason that many diseases are not treated until late in their course. The Affordable Care Act has helped millions, but the problem is not solved. The egress of insurance companies is not because the ACA is failing, but rather because they want more profits (

We still have a system that is flawed. It still makes it difficult for many to get needed care. And bankrupts many who try to pay. But, it is better that what it was, even if more changes are needed.

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