Beware siren song of private-payer care

In the U.S., the doctor is in, but maybe financially unavailable

By Jessica Schorr Saxe, M.D.
Vancouver Sun, Aug. 25, 2014

The middle-aged woman came to my family medicine practice for a routine visit to check her high blood pressure. It was the highest I’ve ever seen in the office: 280/180. I told her to go to the emergency department for probable admission to the hospital.

Her eyes crinkled, and tears fell silently. I thought she was crying because I had frightened her about the urgency of her condition. I was wrong.

“I can’t go to the hospital,” she said, “I can’t afford it.”

I have practised for more than 30 years in a health centre that cares for low-income patients in Charlotte, N.C. As is typical in the United States, our patients rely on a hodgepodge of funding sources. Almost all patients face some financial barriers to care.

A few have private insurance (increasingly with high co-pays and deductibles), many have Medicare (for the elderly) or Medicaid (for some of the poorest of the poor), and many are uninsured. Of the uninsured, some are “self-pay” and some qualify for sliding-scale charges pegged to their income.

While my patient with extreme hypertension is deeply etched into my mind, I could tell you many similar stories.

The typical new patients in my practice have not had health care for months or years. In many cases, they once had employer-based insurance and access to private doctors, then lost their job and thus their coverage and their physicians. Some cry when they talk about the interruption of these long-term relationships with their doctors.

One such patient had been hospitalized with severe congestive heart failure and had lost his full-time job because of his illness. Although he continued to work part-time, he was uninsured and could no longer see his usual doctor.

It took months for him to see me. When he did, I promptly sent him to a cardiologist who prescribed open-heart surgery. He received it, but he could have died waiting for care, as thousands of Americans do every year.

The constant churning of patients in and out of coverage, or in and out of private insurance plans (each with a restrictive network of providers), is cumbersome and costly. Such transitions require patients to seek out new doctors who request and scrutinize old records and sometimes order tests, not realizing they have already been done.

The U.S. system creates other challenges to providing good care. Some patients miss appointments simply because they don’t have enough money for their insurance co-pays.

I approach each patient with an algorithm. This patient has Blue Cross/Blue Shield and has these options, this one has Medicare and another set of options for referrals and medications, this patient is on sliding scale and another set: oops, no options here for certain services. It is even more complicated, because the options change.

Unlike many other places in the U.S., we are fortunate at my health centre to have many services for the uninsured, but there are still many gaps. Elective orthopedic surgery, for example, is not even an option.

I have a patient with a painful hand condition and several patients who need knee or hip replacements. Many of them would be able to work if they could afford the recommended surgery, but instead they live in pain and poverty.

I know some people in Canada decry excessive waiting times for elective procedures. The waiting times for patients on the U.S. side are sometimes infinite or until they reach the age of 65 (decades away for some), when they finally receive our Medicare.

Medical care in the United States costs twice as much per capita as in Canada, yet we have tens of millions who are uninsured, two million people a year who are victims of medical bankruptcy, and some of the worst health statistics in the developed world.

As Canada considers the “Cambie case,” i.e. a constitutional challenge to your single-payer system, I urge you to protect and defend what you have. Allowing private payers to jump the queue, and expanding the role of private insurance and for-profit medicine, will inevitably lead down the road to worsening inequities, greater expense, and poorer quality.

Learn from your neighbour to the south. Don’t follow our disastrous example. Improve your imperfect but fundamentally sound medicare system, and continue to enjoy good care, good health, and the financial savings your system offers.

Jessica Schorr Saxe is a family physician in Charlotte, N.C.