DOCTORS’ LOUNGE
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allow. Since they are also working full time
and cannot sit on hold forever in an endless
phone tree of hospital financial advisors,
they generally cannot find out. They can
search the CMS website for doctor rank-
ings and success of total joint replacement
rankings and heart surgery rankings and
so on, but getting a solid out-of-pocket
cost number that includes the doctor, the
anesthesia, the pre-admission testing, the
hospitalist, and the hospital drugs/thera-
py/nursing charges together - it’s not just
herculean, it’s impossible.
Other authors in the NEJM have ad-
dressed this issue recently as well. Drs. Ravi
Parikh, Arnold Milstein, and Sachin Jain in
the March 9 th issue made strong new recom-
mendations for how we educate medical stu-
dents and housestaff about the cost of care.
They pointed out that dollar signs on EMR
formularies and pressure from hospital care
management specialists to discharge those
who no longer meet “inpatient severity”
serve to highlight the cost to the hospital
or the government. They note, “In current
education on health care costs, we learn to
answer the question, 'How Much?' But we
fail to ask, 'For Whom?' Costs are different
for different stakeholders.”
Our primary responsibility as physicians
is always to the patient. Always, always, al-
ways and forever do I worry how much
my medical fears, on their behalf, will cost
them. I am anxious that they suffer not; I am
anxious that I won’t miss something danger-
ous or wait too long and let a serious illness
become a life-threatening one; I worry that
the medicine that works the best is the most
expensive one, but prescribing a cheaper
one might work out better in the long run,
since that respects their actual ability to fill
the prescription. Physical therapy can work
so many wonders, but for commercially in-
sured patients, it is often out of reach inside
that $5,000 deductible.
The doctor in training is trying to figure
out what is wrong and how to fix it, and care
might involve multiple consultants and tests,
and result in post-discharge follow-ups and
medications and PT that the patient has no
intention or capacity to afford. Only 20-40
percent of eligible patients complete all of
their Cardiac Rehab because of the cost.
What happens then? They get worse again.
These authors recommend med student/
patient shadowing for a full day of health
care, home visits, and care coordination by
students so they see firsthand the logistics,
the bus fares, the copays, the missed work
hours, the child care arrangements, etc. etc.
- all of which empty the patient’s pockets.
They recommend that we keep in mind that
what is cheaper for the institution often
means cost-shifting directly to the patient.
They recommend computer algorithms that
demonstrate costs to all the stakeholders,
so that we can be aware of the pressures
on each.
I recommend, as Congress goes through
the process of what has been called “repeal
and replace” for many years now, that they
remember the economic point of all this:
have children grow up healthy to become
adults who are well and working; and care
for the old and disabled humanely and well.
Research done by Dr. Goodman-Bacon for
the National Bureau of Economic Research
in Dec. showed that Medicaid use in child-
hood led to better health and lower use of
public benefits in adulthood. He stated that
Medicaid policy currently saves federal and
state governments $21 billion yearly overall.
Then, of course, at least if you believe
the health insurance companies’ ads, there’s
compassion for one’s fellow human, too. I
hope to see lots of that soon.
Dr. Barry practices Internal Medicine with
Norton Community Medical Associates-Bar-
ret. She is a clinical associate professor at the
University of Louisville School of Medicine,
Department of Medicine.
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