why how we pay for healthcare actually matters

I have a patient in my practice, Francisco, who showed up to the walk-in clinic one day looking awful. His wife had driven him— insisted, he told me.  Fransisco was an always-upbeat guy who I had treated over the years for the major and chronic (uncontrolled diabetes) to the minor and self-limited (smashed thumb). He’s an auto mechanic who supports a big extended family. He’s hard-working. He always says thank you. He’s downright jolly, even when life gives him lemons. But this day, he was struggling to remain cheerful. He had nearly fallen in the shower, he told me, and felt dizzy, weak and sweaty. He had a headache, or sometimes more of an upper back/shoulder pain. It wasn’t going away.

I had a sinking feeling as I asked the medical assistant to check his blood sugar and vital signs. Francisco’s medical history put him at high risk for a number of life-threatening problems— things like a heart attack, or a diabetic coma. His blood sugar was normal. Damn, I thought, that would have been relatively easy to fix. His heart rate was too high. His oxygen level was too low.

He needed an EKG. He needed some blood tests. A full-service primary care clinic would have those things. My free mobile clinic did not. Even if I had more resources at hand, though, he needed to go to the emergency room where there were nurses and cardiologists and resources and machines. They would evaluate him, stabilize him, and treat him. They have to— it’s the law. But then, I knew, they would bill him. He might quality for emergency Medicaid, but given his and his wife’s modest incomes and their family’s complicated immigration status, it wasn’t clear whether he would. But when you need medical care right now, you’ll figure out how to pay for it later. You want to live right now.

I looked at his chart the next day. The emergency physicians did the EKG, they did the lab work.  He didn’t seem to be having a heart attack.  They did a lot of other tests, too— that to my eye, were varying degrees of necessary and/or helpful, but all expensive. He got some fluids. He got some medications. He got better. He went home.

I was immediately relieved. But also. . . I felt guilty. He was going to get a ruinous bill from the hospital when he turned out to be OK after all. I wasn’t wrong to send him. He needed to go. He was like a textbook case for someone who needs a cardiac workup, STAT. If I had sent him home, I would have been risking his life. But still, it pulls at me: could I have somehow saved him from financial disaster without compromising his health? The answer is no, I couldn’t have done anything that day to fix the problem. But WE can, by changing the way we deliver and pay for healthcare in this country. I tell this story because it’s not abstract– it’s very real.


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