Question from the Quora Blog on Healthcare in the United States: Do American Physicians Allow their Patients to Die if They Have No Money to Pay for Care ?

Gentle Reader – I was asked to answer this on Quora (www.Quora.com) and thought it might prove of interest.  Comments are, as always, requested.

AJL

Query:

Does it really happen that doctors let their patient die because patient’s family can not provide money for the treatment ?

While there is much wrong with the American Health System, one of the things wrong is NOT that patients are allowed to die because of inadequate finances; at least not precisely in that manner.  Let me explain.

The Health System in our country consumes a very large fraction of our Gross Domestic Product, about 17.5% this year.  For those dollars spent we have some of the worst outcomes in the OECD (Organization of Economic Cooperation and Development) database.  Basic things, preventive care for example, we do poorly, and the data show this (If you want an example of the data, go to my blog Notes from the Southern Heartland and read Problems in Paradise).

Other things we do rather well, although these tend to be the high technology things.  So, for example, we have some of the best outcomes in the OECD database for cervical cancer, and colonic cancer, and one of the highest rates of screening for cervical cancer.  Our intensive care units are remarkable places where we often save lives that were thought to be lost.

And the quality movement in medicine – while not an American movement – is heavily influenced by us.

So, we do some things right and some things wrong, but this still isn’t an answer to your query.

Let me tell you a story, if I may, that may shed some light on this question.

Some years ago, between 1995 and 1999, I was the Chief of Emergency Medicine at a large southeastern academic medical center.  As the Chief, I reviewed cases that went bad and, of course, did clinical work myself.  One of the things that struck me so forcefully, and somehow I had not noted this before, was the disparity in how patients were treated. Not in our ED, but after they left.

A severe diabetic (with health insurance) would come into the ED with his glucose out of control.  We would stabilize him, decide whether or not he needed to be admitted and, if admission was not needed, would send him home with a phone number to call for a clinic appointment.  Although he might miss the appointment, if he DID call and then show up, he would be cared for.

Now, another diabetic – equally as sick – shows up.  But he is uninsured.  We do exactly the same thing as in the case above.  Stabilize, decide whether to admit or not, and then, if admission is not needed, send him out with a number to call for an appointment.  Our Social Worker – these are some of the most wonderful people I work with – would try to get the man Medicaid insurance, a joint state / federally funded insurance.  Even if Medicaid was obtained, when this man called for his appointment he would either be told Medicaid isn’t accepted or would be given an appointment so far in the future that it was no appointment at all.

Now when this second man comes back to the ED, again with his diabetes out of control and this time with a life threatening soft tissue infection, we admit him, stabilize him, probably take him to the operating room for a debridement procedure and, two months later when he is better, we send him out.  The surgeons will see him at least once in the clinic, but he will still have no primary care.

And the cycle starts again.

So, you see, it is not that American physicians let people die because they are poor.  If anyone with an emergency condition showed up to our ED, we would do all we could for them, whether they had insurance or not.  But our system – until the advent of the Affordable Care Act – would deny ongoing, followup care to people based upon their ability to pay.  Yes, of course, some  – maybe most – primary care physicians would do some charity care.  And yes, of course, there are some free clinics and church-run clinics in our country to which people without money can go.  But as an organized, civil society we had, until recently, no organized response to the need for primary and preventative care for those uninsured and under-insured citizens. The result of this dysorganized approach is that people died.

The fix for this situation is straightforward and yet not simple.  If you follow the American press, you will see the vituperative nature of the attacks of Koch Brothers-funded surrogates on the Affordable Care Act, so-called “ObamaCare”. The thing is, the ACA isn’t very good, actually.  But it is a step in the right direction in my opinion, the early missteps not withstanding.  If we have primary and preventative care for all of us, and all are insured, our health-related outcomes will improve; our costs will likely decrease (although this is a bit more complex, I will talk about this if you want, later); and the price of an aspirin tablet in the ED will decreased from $ 15 to pennies, as it should be.

It has been my honor, over some 30 years, to work with physicians, nurses, advanced practitioners,students, Social Workers, and Fellows who spend their lives caring for others. People who cleanse and heal the wounds of body and spirit of our ill brothers and sisters.

The problem with our system is organizational and conceptual.  Hopefully, we have begun to correct this.

About AJ Layon

AJ Layon was, for 28 years, at the University of Florida College of Medicine, in the Division of Critical Care Medicine, in Gainesville, FL. For the past approximately 10 years, until September 2011, he was Professor and Chief of Critical Care Medicine at UF; In September of 2011 he became System Director of Critical Care Medicine in PA. While his interests are primarily related to health care, health care reform, and ethical issues, as a citizen of our United States and our world, he will occasionally opine on issues of our "time and destiny". You are welcome to respond to him at ajlayon@gmail.com.
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