How to make treatment decisions while considering the cost of care

Aunt Martha’s Clinic doors open at 8:30 a.m. I review my patient schedule for Monday: 20-plus patients booked every fifteen minutes, with slots left for walk-in emergencies. The patients often don’t speak English, possess no insurance or rely on Medicaid and are financially strapped when it comes to paying for medical care. Some are immigrants from as far as Indonesia and Africa and as close as Mexico. They have told me stories of walking thousands of miles to enter the United States, all in the hope of a better life, with great appreciation for American ideals and values.

The rest of the patients are part of the working class of America, including electricians, plumbers, landscapers, paramedics, police, secretaries, construction workers, bakers, Amazon stockers, Uber drivers and factory workers, just to name a few. It is an honor and privilege to serve them every day and see how hard they work for their families. They worry about their health care, and often whether they can afford the medical treatments that I recommend.

In this article, I will share stories of how the cost of care affects underserved patients and provide some guidance to physicians for working with this population.

ACA expands access but challenges remain

Through the Affordable Care Act (ACA) of 2010, also known as Obamacare, many of my patients have obtained their current health insurance. An estimated 35 million+ people now receive insurance under the ACA. The ACA’s provisions greatly helped patients with health insurance receive coverage for essential health needs such as preventive care and screenings; however, there are still challenges to delivery of health care through the preferred drug plans insurers rely on and prior authorizations for imaging studies.

Hoping for care

For example, one of my patients who was diagnosed with coronary artery disease also has uncontrolled Type 2 diabetes. Cardiology recommended Ozempic to control his diabetes rather than injecting insulin because insulin has not worked. However, his insurance company would not pay for Ozempic and recommended continuing the insulin. Unless he was able to pay $600 a month, insulin was his only option. The medication has decreased his HgbA1c, but not to levels that even remotely control his diabetes in order to stop the progression of CAD.

Therefore, as an alternative I reached out to my network of providers and will send him to endocrinology with the hope that they can obtain medical coverage for the patient since the preferred treatment has failed. There are countless patients like this one who are receiving substandard care because the insurance will not cover the better treatment option.

Humanity in medicine

Another patient of mine with no health insurance at all had a loud heart murmur. I sent him to an independently owned health facility where there are radiologists and cardiologists who will review studies for a negotiated fee. The study came back with critical aortic stenosis and since the patient told me one of his symptoms was shortness of breath, I sent him to the ER.

He went and then showed up in the office on Monday with orders from the ER doctors to see their cardiologist within the hour. This prompt display of care from my colleagues shows how they don’t turn away uninsured patients. This is a true testament of the humanity in medicine.

Tips for providing cost-effective care to underserved patients

Patients from an underserved population may have several medical conditions that require evaluation and treatment. Prioritize which medical problem to focus on first, and realize that due to cost constraints you may not be able to order the labs and testing for a complete workup of all the medical conditions right away. Multiple visits may be needed to provide adequate care to the patient.

Additionally, patients may need to travel far distances to see a specialist who takes their insurance. The patient might see the specialist only once and because of transporation costs choose not to return to the specialist for follow up. Therefore, as a general practitioner, you should try to complete as much of the lab workup and imaging studies as possible before sending the patient to the specialist.

Develop a network of physicians that your patients can go see with their Medicaid insurance or even as an uninsured patient. The supportive care from your colleagues will ensure good outcomes and will be more cost-effective than sending them to the ER.

Know the resources in your community that your patients can turn to if they suffer from financial stressors from their family/living situation. Resources at your City Hall and local home health agencies may be available to assist with cost effective care for patients.

Familiarize yourself with pharmacy programs that provide affordable medications. In Illinois, the 340b program through Walgreens requires drug manufacturers to sell discounted drugs to patients who are considered underserved or vulnerable. You can send scripts electronically to Walgreens with a pharmacy note attached requesting coverage through the 340b program.

Pediatric care

Since pediatric patients are also seen at Aunt Martha’s Clinic, I spoke with one of our pediatricians, Dr. Smitha Samuel, to gain her perspective on delivering health care to socioeconomically disadvantaged children.

“Being a pediatrician and the State of Illinois having the “All Kids Program” for children, most of my patients already have insurance, or can easily apply,” Dr. Samuel says. “The Illinois All Kids program offers health care coverage to children at no cost or at low cost. Premiums and co-payments are determined based on the annual family income and size.

“There are situations where I have kids coming in as illegal immigrants or legal immigrants from other countries who don’t initially have insurance yet. They pay based in a sliding fee, or based on their family’s annual income. I’m not sure what the actual financial or monetary cut-off is. I know through Aunt Martha’s it’s a Slide A thru E. A person who is considered to be at the poverty level, or a Slide A, would pay about $20 per visit and that would include the visit and bloodwork, and I think the vaccines are included in it.”

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