Recently I admitted a relatively young man to the hospital for cellulitis. Cellulitis is a bacterial skin infection that resides in the space between the skin and the tissue just below it. Imagine it as the layer of dirt between your carpet and the floor. Once bacteria gets into that warm, wet area, it can spread in almost any direction with little resistance; if you are a staph or strep bacterium, that little compartment is heaven on earth. Cellulitis, left untreated, can cause horrific injury in days or even hours, leading to a burn-like destruction of skin, loss of limb, or even death if the infection enters the bloodstream.
Unfortunately this relatively young man had no insurance. When he arrived in the emergency room, the doctor there started him on two antibiotics, clindamycin ($$$) and levofloxicin ($$$$). I was not sure I understood the choice of these two, or why he picked two instead of one. Perhaps he was acting on personal experience of what has worked or not worked in the past, or maybe he had performed a lot of cultures recently on patients and felt, based on what he was seeing in the community, that this combination was necessary.
His choice certainly worked. By the time I saw Relatively Young Man on the floor his infection had already improved. I decided not to change anything, in accordance with my Prime Directive of Medicine: Don’t change a patient’s medications if they are working. The last thing I needed to do was simplify his regimen and watch him get sicker. Call it defensive or even chickenhearted medicine, but I was not about to put myself in the position of having to explain to a patient who had suddenly gotten sicker why I changed an antibiotic regimen that was initially working.
But I knew what was coming. This guy had no insurance, and his two antibiotics were expensive. When the time came for discharge, I would be writing him two very expensive prescriptions to continue at home. I warned him long before he left the hospital that this would be the case. He nodded in understanding, or perhaps that head bob was triggered by momentary disturbances in the earth’s magnetic field.
Anyway, in 5 days the cellulitis was almost gone and there had been no fever for 36 hours. His blood work was normal, and all his cultures were negative. Since I had no positive cultures to go on (cultures allow us to tailor antibiotic regimens more precisely and eliminate expensive medications), I had to stick with what was working when I discharged him. I wrote him a prescription of both levofloxicin and clindamycin. To keep the price of the meds down I abbreviated the antibiotic course to only 5 days.
A weekend passed, then two days after that, and I got a call from a pharmacy about Relatively Young Man. He had shown up with the two scrips I had written, but complained that he couldn’t afford to buy them. After a few seconds of quiet, frustrated breathing I cancelled both scrips and put him on a third, cheaper medication that I thought would work. Though I was guessing.
Four days. He went home and walked around without antibiotics for four days because he couldn’t afford them. I concede that the two prescriptions together probably cost about $200, but he could have easily lost his leg. If I could pay $200 to save my leg, I would. And he couldn’t argue that he didn’t understand the severity of his situation. He had come into the Emergency Room a week earlier with a leg the size of an elephant’s, in excruciating pain, and with a fever of 104. He knew what could happen.
If he couldn’t afford $200, he could have called me at any time and I would have tried changing the meds. But he waited, and took his chances in a very serious situation. He was very, very lucky the infection did not come storming back and land him in the hospital all over again.
Maybe I am showing the blindness of affluence, but I cannot understand why a person in the United States could not come up with $200 in an emergency. Maybe he didn’t have it, but all his friends, family, and neighbors, or local church couldn’t help him out? No one likes to borrow money, but it beats living with one leg. He had a job. And this was a one-time treatment, so there was no concern about ongoing costs.
I have two theories about why he waited 4 days at considerable medical risk to do something. Either may be true, or a little of each, but both have sobering implications for the future of health care in the United States.
The first theory is that he figured he could always go back to the emergency room if things got bad. A lot of uninsured patients think this way. ERs are required by law to treat all comers, and this leads many of the uninsured to think of the ER as their health care provider of last resort. This approach, while convenient, is also the most expensive solution possible for society. From a taxpayer’s point of view, anything would be better than waiting for a patient to advance to the brink of death before the public steps in. Besides being inhumane, it is, from a cost-effectiveness standpoint, flat-out stupid.
The second theory is that he felt better and thought he might be able to do without the antibiotics. He did not know me prior to being admitted and may have been afraid that if he called me I would not react kindly to a request for cheaper medication. So he took his chances. Perhaps if he had been my patient before and knew me personally he would have spoken up. If this is true then his treatment failure was a primary care access problem. Since he didn’t know that I would have worked with him, he didn’t ask.
Of course, the problem with both of these theories (and any additional ones the reader may supply) is that Relatively Young Man bypassed every opportunity to act. Rather than trying to work the healthcare system in some way, he chose to do nothing but wait for the system to come to him. He could have borrowed the money. He could have called me for a different prescription. He could have filled the prescription for the cheaper of the two antibiotics and left the other unfilled. Instead, he did nothing.
If the infection had come roaring back, he would have landed back in the hospital, back on my service, again probably on the taxpayer’s dime. He already had one hospital bill he probably can never hope to pay, and he was bucking for a second.
It should make no difference to the average American whether Relatively Young Man was dumb, smart, shy, foolish, reckless, oblivious, or if there was a doctor-patient communications problem. What should make a difference is that this scenario is playing out right now in every city in our country, and billions of dollars are on the line. There is a Relatively Young Man in your town right this moment, nursing a festering medical problem that will erupt into a major one in a few days if he does not find a doctor who will treat him for a very low cost. A certain percentage of Relatively Young Men will crash and burn, landing in the E.R. a septic mess, sucking a little more of the lifeblood out of the system you are hoping will be there for you when you get old. All for $200 worth of pills.
A lot of people (doctors included) huff that Relatively Young Man could have paid the money if he really wanted to. He could have cancelled his cable TV or turned in his cell phone, quit smoking or skipped a month of fast food visits to save the money. Probably true. However, and this is personal experience talking here, he won’t. He will sit at home, watching cable TV, puffing on a $4-a-pack cigarette, pulling at his third Bud Lite wondering why he can’t afford medical treatment. This is just the way things are. We may not like it, but the fact that he cannot cope with his financial situation will not change reality. He is on a deadly collision course with a $30,000 hospital stay at public expense, and he is not going to do anything about it.
At least Relatively Young Man eventually called my office. He is now on a much cheaper medication, though there is no guarantee it will work. Hopefully it will work. I never found out; he has not kept his follow-up appointment with me.
It is my belief that our broken-down medical system cannot be fixed without a major overhaul. But since there is not a single politician in the United States with the guts to do what needs to be done, I would like to propose a low-cost remedy to the problem of the Relatively Young Man.
Since Relatively Young Man will always be around, and will likely never change, it is up to us to do the changing. No, it is not fair. This is not about fair. It is about saving your medical system for yourself.
Suppose doctors had the ability to write vouchers for free prescriptions. Each doctor could have an annual budget of, say, $5,000, which he could disburse to any patient to pay for medications. The money could only be used for medications, nothing else, and its purpose would be to keep patients out of the hospital. If I had such a resource at my disposal in this case I could have written a voucher for $200. The voucher would have only been good for 24 hours, which would light a fire under Relatively Young Man to get the prescription filled quickly and start his treatment on at timely basis. Such a system could save thousands of ER visits and possibly prevent many hospital admissions or re-admissions. The savings go right into your pocket, my friend.
The great flaw in government-managed solutions is that they are necessarily bureaucratic. With all the rules and regulations, there is no guarantee that money will get to the right person at the critical time. (I could cite Hurricane Katrina as a classic example but let’s not get off on tangents and tirades.) This is where doctors come in. As a doctor, I know my patients and am in the best possible position to judge when a $200 disbursement might keep someone out of serious trouble. No government or charity office could ever hope to consistently do that.
Every doctor knows at least one Relatively Young Man. With a little money, and without changing the health care system as we know it at all, it may be possible to save huge amounts in the long run. Does anyone have the courage to try, or will we allow the infection to continue to spread?