• Rosalind Kaplan, MD

A Civilized State of Affairs?

It's been quite a while since I've posted. I wasn't sure if I would continue after I hit the one year mark after leaving primary care, but I feel like it's important for physicians to keep talking about what we see going on in the medical system. Working in urgent care, I've started supervising some of the other providers at sites other than my own- 19 sites in all in Pennsylvania and Delaware- so I hear about a lot of patient situations.

The urgent care site where I work is in an affluent area. Most of our patients are employed or retired and have health insurance, though I have certainly encountered a number of patients who don't. Many of these patients are young adults, just off their parents' insurance, who are trying to manage with part-time employment or who are working within the 'gig' economy, and cannot yet afford to buy health insurance. Some of our sites are in less monied areas, and there are many more patients who either have no health insurance, or who are very under-insured.

Here's what I'm seeing from my vantage point:

1. For patients who must pay out-of-pocket, urgent care is often the only healthcare they access. Our urgent care centers have a reasonable set fee for a single visit, and we are able to dispense many commonly-used medications at a set price, also reasonable. The caveat to that is that additional services, such as X-ray, EKG, nebulizer treatments, medications, orthopedic equipment and IV fluids cost extra. We can get around the fee for a blood draw by sending a patient to a commercial lab, but they will still have to pay for the actual blood tests offered. We try not to rack up charges for these patients, but sometimes they are in desperate need of care, as they have serious ongoing problems, and have avoided care or fallen out of care because of cost.

2.Patients who have high copays for ER or hospital-based visits try to avoid the ER, so they come to urgent care at night, on weekends, and if they can't get in to see their usual doctors. This is a good thing on one level, as it shifts the burden of less acute or serious illnesses to a fast-track, less expensive, more efficient venue. But it can also be a bad thing when patients are so eager to avoid the ER that they come to urgent care with extremely serious problems that actually belong in the hospital setting. Sometimes patients don't know how serious a problem is. Sometimes they do, but nevertheless hope that urgent care will be enough, which endangers them.

3.We often see patients with long-term issues that should be treated by the doctors who already treat them as outpatients. If they have new or worsening health problems on a weekend or in the evening, urgent care is a helpful addition to ongoing outpatient care, and we can get patients through an acute episode or a complication, thus avoiding an ER visit. But way too often, we are seeing patients for care of chronic problems during regular working hours because their primary care doctors don't have time to see them, or because they can't get an appointment for months with a specialist they need to see. This is not a condemnation of those primary care doctors or specialists, nor is it a condemnation of the patients. There is a real shortage of primary care in my area of Pennsylvania. And shortages of certain specialties, specifically cognitive (lower-compensated) specialties like endocrinology and rheumatology. We are happy to try to help these patients in the urgent care setting, but their needs would truly be better served by ongoing care with a provider who knows them and can follow up on a regular basis.

Here are a few examples from my last few shifts. I'm changing details to protect patient identity.

-Last week, I saw a 26 year old man who works full-time. He has had no insurance for the last two years while he was finishing college and working part-time. His father lost his job, so he was not able to be on a parent's insurance from age 24-26. He still has no insurance because his job is new, and he will not be eligible for benefits for 90 days. He can barely afford rent and food currently, so he has not purchased his own insurance. His income over the last two years was too high, however, for him to qualify for Medicaid.

He presented for an unusual infection, one that gave me concern that he could be immunosuppressed. His past medical history is remarkable for a hematologic malignancy that was treated 6 years ago. He had regular followup until he lost insurance 2 years ago.

I treated his infection and discussed the need for further evaluation and for followup care with oncology. He's working on coming up with a way to pay for care.

-A couple weeks ago, a 70 year old patient with known coronary artery disease came to one of our sites. He was having chest pain and palpitations. He has a cardiologist, who told him by phone to call an ambulance. Afraid of the cost of an ambulance and an ER visit, he instead presented to urgent care. When he checked in, his heart rate was in the 150's and his blood pressure was extremely low at 70/50. 911 was called. Because our urgent care center is equipped for potential true emergencies (not all are), the staff was able to put him on a cardiac monitor and establish IV access, and a defibrillator and drugs for advanced cardiac life support were available if needed. Fortunately, EMS arrived and he was transferred to the ER quickly. However, it was very clear that he would have been much better served from the get-go by a hospital with a cardiac cath lab. The hour+ that it took for him to get to urgent care and then be transported to the ER could have constituted a fatal delay. We all breathed a sigh of relief when we found out he'd made it to the hospital safely.

-A middle-aged patient with a facial mass presented to urgent care. The mass was a known malignancy; it had been resected in the past, but had recurred. The medical bills from the previous resection included a 'surprise' anesthesia bill from a provider outside the patient's insurance network, a bill for her insurance deductible, and copays from the OR, the surgeon and an imaging study, adding up to over $10,000 dollars. She was unable to pay most of this, and is still paying these bills now. She did not return to for care when the mass recurred because of her financial situation. She was not eligible for Medicaid.

She was in urgent care because the mass was now purulent and painful. We were able to treat her for a cellulitis around the mass, but there is destruction of skin, subcutaneous tissue and possibly bone that required much more complicated intervention. She refused a hospital transfer, fearing financial ruin.

These are only a few examples from just a couple of days in urgent care. None of these patients are truly indigent. In fact, all of these patients are employed. We supposedly live in an affluent and civilized country. But these stories are evidence that this country is not really civilized at all; our Medicare and Medicaid 'safety net' does not make enough of the population safe. Millions of people are managing at subsistence level, until an illness turns subsistence into poverty. Fear of financial ruin prevents many from seeking care, ending up in loss of life. Meanwhile, a tiny segment of the population can afford multiple lavish homes, expensive vacations, and private jets. Is this really the civilization we want to perpetuate?

#patientoutcomes #medicalpracticemodels #urgentcare #physician #compassion #physicianburnout #doctor #medicine #emergencymedicine #health #negativepatientoutcome #primarycare #patientsafety #medicaladministration #medicaleconomics

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