From the Wards: Looking Out at Insurance Barriers to Ongoing Care

July 21, 2021

Comment by Isabel Ostrer

As a first-year internal medicine resident, I entered the hospital eager to both treat patients’ acute illnesses and empower them to stay healthy outside the hospital. But only weeks into residency, it’s already abundantly clear that very little of a patient’s health and well-being is tied to their hospital stay. Sure, we gather comprehensive histories, run tests, think critically about a patient’s medical problems, and dole out diagnoses and drugs to treat a patient’s immediate clinical crisis. But the best critical thinking and immediate pharmacologic management can only go so far if ongoing care is suboptimal. And I’m learning how insurance can dictate medical options.

Mr. Y came into the hospital after experiencing crushing chest pain for many hours. By the time he arrived, his heart attack had likely been in full swing for half a day. He had his blocked heart vessel opened with a stent, but in the interim he lost blood flow to a significant portion of his heart muscle, killing some cells. He ended up developing an abnormal heart rhythm, atrial flutter, where the top chambers of the heart don’t pump blood effectively. He needs a specific medicine to prevent him from developing blood clots that can lead to a stroke. Between two nearly identical (from a medical perspective) options, I prescribed the one that could be taken once a day, instead of twice a day. More convenient, I thought, and moved on. I have no idea how much the medicines I prescribe cost patients. Luckily, I got a message from the clinical pharmacist asking if I would consider the other option because it would cost my patient $17/month, instead of $200/month. A 92% reduction. For many of the patients I see, a seemingly inconsequential medical decision I make can quite literally mean financial ruin. This compromise to convenience seems reasonable enough, but what if the pharmacist hadn’t called?

Ms. M, another patient I cared for in the hospital, has end-stage heart failure. She came into the hospital in cardiogenic shock – her heart was so weak it couldn’t pump enough blood to the rest of her body. She ultimately recovered well enough to go home. Like Mr. Y, she needs to be on life-saving medicines to keep her heart failure symptoms in check, or else she will be hospitalized again and again. I wanted to set her up for success so messaged the case manager on my hospital team – an incredible patient advocate – to ask if we could enroll her in a home health program where she would get help managing her medicines – to keep her alive and out of the hospital. His reply read, “Sure, I can try, but she has really poor insurance, so it might be tough to arrange home health.”

As a doctor in training, I’m soaking up all the medical knowledge I can so that I can give my patients the best medical care possible and the greatest chance of staying healthy outside of the hospital. I’ve quickly realized this is hard work in a system that is short-sighted. Acute interventions in healthcare, especially inpatient, are very well-reimbursed. But the longer, harder work of “health” — making sure patients can access medications and manage their chronic conditions — often falls by the wayside.

Medicare for All would offer patients a better chance at success, by assuring high quality insurance for everyone. An insurance system that focuses on patient well-being over profit is one that meaningfully negotiates drug prices to ensure that life-saving medications are affordable for patients. It is also a system that treats care at home as a necessary service that isn’t limited by whether you’re privileged enough to have “good” insurance.