Health Care Confidential, From The Inside: Why Health-Care Reform?

The health-care reform debate has become so poison- and rhetoric-filled that it's really easy to lose sight of the primary issue: How are individuals affected by our current health-care system? Before we can support change, or dismiss the need, it's important to grasp what truths our neighbors and friends are living with daily, the realities they must accept. In these essays, four local adults describe their lives as shaped by their work and families, and their corresponding health-care coverage. From a doctor's lament to a firsthand reckoning of end-of-life counseling to an eyes-wide-open account of an uninsured heart attack waiting to happen, our essayists offer a very personal view of why changes are needed in our current health-care system.

Dr. Mark Green, 56, practices general internal medicine at Blount Memorial Hospital in Maryville. He has been interested in health-care reform for almost 20 years, and started the website OurHealthReform.com. He is married with four children and three grandchildren.

There are many reasons why we need to support the reform of our health-care system. Some of them are obvious to all but the most casual observer, while others are evident only to those who are intimate with the system itself. Most everyone can, however, identify with the many stories of people for whom the current system does not work. This would include people who have no insurance, who have lost their insurance, those who can get no coverage due to pre-existing conditions, those who are dropped by their insurance companies after they became ill, or those whose insurance coverage simply let them down.

In the early 1990s, I saw a 32-year-old woman in the emergency room who had come in to be seen for an inflamed left breast. It appeared to be a simple case of infection and I was called as the next doctor on the "back-up list," which is a list of doctors that is kept in the ER to assist people who have no insurance or no local physician. I examined her and placed her in the hospital for IV antibiotics, and she initially responded well.

However, as the tenderness and swelling improved, a follow-up exam suggested an underlying mass. Ultrasound confirmed the 1-centimeter mass deep inside her breast and I discussed the need for a surgical consult with her. She was reluctant to proceed as she had recently lost her job, her insurance had lapsed (as she could not afford the Cobra insurance premium), and her house was near foreclosure. She had just found a new job and her insurance would not become active for 90 days.

Though I found a surgeon who would biopsy her for free, I could not talk the patient into moving ahead until her insurance was in force. I saw her every four weeks for rechecks of her breast and on each visit it was revealed that the mass to be slowly enlarging.

She finally got her insurance and then her biopsy, which did prove that the mass was malignant. She ultimately required a simple mastectomy and she did well. Though she continues to be cured, I am still haunted by the realization that she could have done just as well with a simple lumpectomy and radiation treatments if she could have gotten her biopsy three months earlier.

Several years later, I saw a 44 year-old man in my office for a complete physical exam. On his review of symptoms, he described episodes of feeling profoundly fatigued on exertion, but that would resolve fairly quickly with rest. I could find nothing on exam and his risk factors for cardiac disease were low, but for this very believable patient, the most worrisome possibility was occult heart disease. A standard exercise stress test revealed nothing, though at higher levels of physical output he seemed to fatigue out of proportion to expectation.

I requested that his insurance company allow us to perform a myocardial perfusion study, which is a nuclear medicine study, to reevaluate his profound fatigue at exertion. His insurer refused to pay for the study as his other studies were negative for heart disease. The patient was unwilling to risk being stuck with the $3,000 price tag and so refused to have the study performed.

Three months later he was rushed to the ER with his fatigue back, now accompanied by shortness of breath and severe sweating. His EKG was now abnormal and emergency cardiac catheterization revealed a 95 percent occlusion of his main coronary artery. Fortunately, a stent could be placed and he survived with only a mild amount of damage to his heart. It should be noted that this patient had a "good" insurance policy and was fully employed.

Though his insurance company failed him, it was not itself at risk in any way as they did not tell us not to order the test; they just said they would not pay for it. It was the patient who decided not to risk the financial impact. The courts have routinely supported the insurance companies in these disputes.

Recently, I have had a 62 year-old female patient who experienced weight loss for six to eight months. She had seen her primary care physician and the work-up was negative, including no blood in her stool. Her previous doctor had recommended a colonoscopy, but her insurance company refused to authorize one as she had had a negative colonoscopy four years earlier and there was no blood in her stool now to suggest colon pathology as the cause of her weight loss. Now, six months later she was again pushing to find a cause.

At the physical exam, she definitely had an ill appearance and clearly had lost weight. The rest of her exam was negative except for her rectal exam. Again, she was negative for blood in her stool, but there was a hint of a mass effect on her pelvic and rectal exam. This time her insurance reluctantly agreed to allow a repeat colonoscopy, which then revealed a 4-centimeter colon mass. Further work up showed that she already had disease in her lymph nodes. She has since had a diverting colostomy and is currently considering further treatments.

There are few frustrations in medical practice to compare to what one feels when an insurance company refuses to authorize needed testing. There should be no third-party employees standing between a patient and their doctor. Neither private-sector nor government-sector employees should have that right. This behavior is always associated with maximizing the company's profit margin. When they decline to pay for a test and a patient is harmed by that refusal, they are generally protected by the courts.

We need a major overhaul of how health-care delivery is reimbursed. The delivery system itself is functional. We must have a payment system that is not obsessed with the profit margin, but that concentrates on delivering as much of the health-care dollar as possible to be used for patient care. This will never happen as the system exists today.