My Nicaraguan pediatrician friend astutely summarized her work: First you make the clinical assessment, then you make the financial assessment. In other words, a clinician may know the right treatment, but what good does that do the patient if the treatment is entirely out of reach financially?
In the clinic where I work, we don't take insurance. It's not a concierge practice but a church-based one, run on grants and hardscrabble for decades. For a provider, there's something freeing about not having to consider insurance. There's no frantic search through formularies, no restrictive list of specialists, none of the prior authorizations that suck up time and stamina--all things that have nothing to do with patient care but must happen in the insurance world. None of that.
There's also none of many other things, too. The clinical plan for evaluation and management is immediately filtered by possible and impossible, and then the possible list is sorted by cost. I find myself telling patients, "If everything were free and available, we would...,” and then proceeding to explain the ideal approach, the thing we are not about to do--or, in some cases, the thing we will try to do that will take months of persistence. Sometimes we talk about other local safety-net options: this clinic has a dermatologist, that clinic has access to a hand surgeon once a month. Always we talk about emergency precautions.
There is benefit to the system from this minimalist approach: The cost of health care is kept fairly low. There can be benefit to the patient, too: The decision to wait on an MRI or use an older generic rather than a newer, not-yet-field-tested medication can be all for the better. But clinical care based on personal finances is not medicine as it should be practiced.
When the skin biopsies from last week’s patient came back indicating squamous cell carcinoma, as I'd expected, how I'd wished he had insurance. His young forearms were spattered with age spots and raw, bright pink lesions and the occasional firm bit due to his years of hard work in the sun and heat, running his own business.
I'd explained the biopsy procedure, the burning lidocaine, the wait, the likely diagnosis. I'd wanted to tell him, “Run! Buy insurance!” But I knew it was too late for the only version he might barely be able to afford.