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    My $4.07 check from an insurer: A sign of the times

     

    A second recent stone case offers more insight into another drawback of a single-payer system. I received a page from the ER at about midnight regarding a healthy 30-something who had walked into the ER earlier in the night reporting terrible sudden-onset flank pain. CT showed a 2-mm distal stone with mild to moderate hydronephrosis. Urine was clean, white blood cell count normal, and no fever, but his pain could barely be controlled in the ER with large doses of IV narcotic and ketorolac. I called in the OR team (the hospital in this case does not keep an OR team in house) and removed the stone ureteroscopically.

    Two weeks later, when I saw the patient back in my clinic to discuss stone analysis and stone prevention, he said I did a great job. I thanked him and asked him if he had any comparison. He said he was new to town (he had no insurance), but he had a history of multiple stones requiring intervention (something he specifically did not mention the night of surgery). I asked why he hadn’t told me that earlier and he said that other urologists had refused to operate on him when he had small stones.

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    Given the recurrent nature of the disease, I then recommended a 24-hour urine collection and a metabolic evaluation. But he declined, stating that it was easier for him to wait until he had a recurrence and then go to the ER.

    In a single-payer system where health care is free, demand becomes unlimited. Why bother with taking potassium citrate that upsets your stomach or drinking sufficient fluid if free high-quality health care is always available? But the situation is worse than that. In a single-payer system where I as a provider am placed on a salary, why should I operate at all?

    Think again about that second case. The odds of passing a 2-mm distal stone spontaneously are very high and the patient in question wasn’t infected. So maybe if he had been admitted and hydrated, we might have avoided surgery entirely. In that setting, perhaps the in-house medicine team could have done the admission and maybe I could have slept that night and not had to call in the entire OR team.

    Have you seen: Is bigger better in today's urology practice?

    It may seem like a crass concept, but I guarantee that it happens—especially as we see treatment algorithms like those used frequently at some of the state-sponsored health care systems that operate near my office.

    I don’t claim to have an answer to the challenge of providing health care to every citizen of this country. I just know that this small-town plumber is becoming frustrated at providing care to patients enrolled in certain government-sponsored health care programs whose reimbursement is nowhere near covering my costs, let alone paying my mortgage.

    If anyone else has experience with this situation or has an idea about how to best make our voices heard, please write me at [email protected] or sign in below to post a comment.

     

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    Henry Rosevear, MD
    Dr. Rosevear, a member of the Urology Times Clinical Practice Board, is in private practice at Pikes Peak Urology, Colorado Springs, CO.

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    • Anonymous
      This scenario happens all too frequently. Working on the outskirts of a major metropolitan city, it amazes me how many people bring family members from foreign countries to the US for care. Once they enter the system by arriving in ER's, they can't be refused treatment. It is an opportunity for our Urology residents to learn but concept of entitlement becomes meaningless when this care is free. I don't think people would expect this from their auto mechanics, plumbers, tree service people, etc. In these cases, it is RARE that I ever get a thank you from people with no insurance. I guess they don't realize (or simply don't care) that we provide this care gratis or for minimal reimbursement. Even if they don't have insurance, a simple gesture of gratitude or card of thanks would be nice.
    • [email protected]
      Henry, welcome to ColoradoCare! I live in beautiful Steamboat Springs but now only practice urology in rural Nebraska. I only do cases that I can walk away from. I work two days a week and am paid for my work based on wRVUs. It is a good model so call me if you are interested.

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