Observations
By: Kenneth Q
Tags: Healthcare, Residency, Family Medicine, Medicine, Doctors

Family Medicine stands at the front line of the challenges facing American healthcare, which is one of the main reasons why I chose to train in this specialty. I wrote this several months ago when I was still relatively new to practicing medicine and didn’t publish until now. Since that time, these points have been cemented in my mind due to seeing even more cases which prove them true.

ACCESS IS CRUCIAL

One of my patients saw me just once in clinic and had a tremendously high blood pressure. I started an anti-hypertensive regimen and asked them to follow up soon for optimization of the regimen. The next time I saw them in person was months later in the hospital; admitted for multiple organ failure/damage due to uncontrolled hypertension. Turns out, after the initial visit they could not afford to come see me. They luckily managed to survive with mostly everything intact, but now required dialysis.

Free clinics take mostly anyone and everyone who comes in, and make do with what they can. For-profit clinics turn people away at the front door. I work at a non profit medical center and our clinic is not free, but we do provide a large amount of charity care and have a high percentage of patients with “less desirable” insurance, namely Medicaid. In this position, I often see patients who come and go based on ever changing insurance status and patients who struggle to have regular follow up due to the cost of each out of pocket visit. These patients predictably end up in the hospital with significant illness from preventable disease. Not having regular access to a physician has significant and glaringly obvious consequences.

COVERAGE IS NOT ACCESS

Due to my interests in the policy and business sides of medicine, I’ve had the chance to talk to many private primary care groups in the area and beyond. The main way they stay afloat, aside from the standard pushing their physicians to see patients at a breakneck speed and doing procedures whenever possible, is to limit which insurances they accept. Industry standard is no Medicaid and no more than 30–35% Medicare. Breaking this rule means losing the practice.

Virginia recently passed Medicaid expansion, giving coverage to 400,000 people. My residency clinic has already started seeing the real effects of the expansion. Enrollment has gone up and previous uninsured patients can now come more regularly. However, clinics like mine are scarce in a field that already has a overall shortage for the current population. Even many Medicaid accepting clinics are feeling the strain and may be forced to start rejecting patients as well. With the American health system in it’s current state, there will be a point where low income individuals will have some insurance product and no one who will accept them, leaving hundreds to thousands of people without a physician while politicians applaud themselves for expanding coverage.

AN MD CAN ONLY DO SO MUCH

I prescribed a medication to a patient who had a relatively uncommon but simple disease, which had the potential of underlying malignancy. If the medication worked, I would know that the disease was not malignant and the patient would be cured. If it didn’t, the patient may need more extensive treatment. The first time I prescribed the medication, it got denied and I didn’t find out until the follow up when the patient told me their insurance rejected the prescription. The second time I prescribed it, I got a message saying I had to prescribe another, less potent and not as likely to help medication. I complied, it didn’t work. The third time I prescribed it, I got another message saying I had to prescribe yet another medicine which could have more side effects and was not indicated. I sent my reasoning and the evidence to be reviewed by insurance and still got denied. Ultimately, I ended up sending my patient to a specialist in hopes that the specialist could either prescribe the medication I failed to prescribe or evaluate further for potential malignancy. The cost of the medication in question? About $35 for the entire therapy (GoodRx price).

Insurance companies dictate what physicians can and can’t prescribe by requiring prior authorizations. Certain medications require the physician to submit their reasoning for prescribing a medicine before the insurance company decides if it wants to reject or approve the physician’s decision. In medical school we were asked “What do you give for a patient with X disease?” in residency we ask “What medications will the insurance cover for X disease?”