Uninsured patients have to wait over a year for procedures, thus we clinicians will send urgent patients needing procedures to the emergency room just to get it within a timely matter. But if all the providers were taking care of all the patients, there would be no wait and the emergency rooms would be for...emergencies.
First patient of the day: Woke up with decreased hearing in one ear and since she's a musician, she was pretty concerned. The ears looked normal. No problem, refer to ENT (the ear/nose/throat doc) this week.
Next paitent: Worsening back pain that radiates down the leg. She had an injury last year and since then, she's been dealing with this on and off pain and now wants to know what's wrong and can it be cured. Neurological exam was normal, thus not an emergency. Pain medications prescribed, MRI ordered to be done next week and follow up with an Orthopedic surgeon, a Spine Specialist to boot, to be seen after the MRI is done. She obviously has a slipped disc, but I wanted to see how severe it was and see if the Spine Specialist would recommend any procedures.
Another patient the same day: Had blood in his ear and because he had perforated ear drums in the past, he wanted to make sure he didn't have another one. Nope, ear drum good. Small laceration in the canal, “but call your ENT so she can evaluate you this week and knows what's going on.”
Ahhhhh, the feel of working with insured patients! You see, I moonlight at a private practice's urgent care where it's clients all have great coverage. Need a study? No problem. A specialist? How does next week sound? There's nothing like being a doctor and being able to provide the medical care that a patient needs! But that's not how it is for the uninsured.
In working a my community clinic for the uninsured, it's a completely different story. One patient I saw had anemia. As I looked through the chart, he had 3 positive stool cards (that screen for colon cancer) in December 2009. I looked at him, “Have you had a colonoscopy yet?” as I looked to compare his previous weights and see he had lost 15 pounds in the last 6 months. “Nope.” I then see in the referral section of his chart that he had been referred for colonoscopy in December, 2009. When I asked for the status of the referral from the referral coordinator, “Still Pending.” I just shook my head. Since I used to work at one of the County Hospitals, I have some tricks to getting patients in. I called the back line for the Endoscopy Suite and asked to speak with one of the fellows. I tell him the story. “Send him to the Emergency Room.” “But he's stable, he just needs an urgent colonoscopy.” “No such thing.” I just remained quiet on the phone. “All right, give me his name and number and I'll try to get him in within a month.” So I gave him all the appropriate information and also got the fellow's name and pager number...a little accountability and of course, promised to name my first born child after him...not really, but it felt like that.
Another patient I saw had tore her biceps tendon 1 ½ years ago. “I'm still waiting to see Orthopedics,” she laments. Are you kidding me? Again, I check the status...”Still Pending.” I sigh as I examine her atrophied biceps muscle. Now I would have sent her to the county emergency room had I seen her from the get go knowing that it takes over a year to get an Orthopedics appointment at county. In sending patients to the emergency room, I tell them, “You'll wait 24-36 hours to been seen, but if it's serious enough, you'll see an Orthopedist in the ER, but at the very least the ER will refer you to see Orthopedics at their clinic within a few weeks. Starting to see why the ERs are so outlandishly crowded? Orthopedics is a special case, because there is not one Orthopedic Surgeon that will take MediCal. So even when a patient has MediCal...all orthopedic problems must go through the county.
A couple months ago, I saw a man in his 40's that had what seemed like an enlarged lymph node on one side. Is was about grape sized, but had been there for about 2 years. Not a smoker or drinker (increase one's risk for head and neck cancer), so I ordered a tuberculosis test and referred him to ENT knowing that it was about a 6 month wait. He came back in one month...TB test negative, but now the mass was the size of a golf ball and rock hard...sounds bad! So....the speech..”Ok, so I'm going to send you to the ER because you can't wait any longer for a biopsy and they are the only ones that can get you into ENT within a week. You'll wait 24-36 hours, so bring a coat, food, a book and just be patient. Seeing a pattern here?
Last week I saw a 30 something year old man who came in because he had an inguinal hernia for a couple of years. He wanted surgery. Yup, he had an avocado-sized hernia. But it wasn't an emergency. “I'll refer you to surgery, but it will take 6-9 months to get an appointment. Then it will take 1-2 years before you get the actual surgery.”
Truly, I can't imagine having to wait so long for my health care. Now some people say, “You see, if we have Universal Health Care, this is what it will be like. It will be like the county.” But that's not correct. You see, the county isn't providing “universal health care”. It provides Safety Net care. Big difference! Safety net care tries to pick up the slack in providing health care to its residents who otherwise couldn't get any health care at all except truly emergent care. And even emergent care wasn't always available for the uninsured. It took a group a young doctors in training in the 80's who noticed that when patients were being transferred from private hospitals to public hospitals for emergent conditions, they would arrive dead! Thus the EMTALA law makes it mandatory for every emergency room to attend to every patient that crosses their threshold irrespective of ability to pay and provide emergent and hospital care if needed.
Let me give you an example of a sort of Universal Health Care that the U.S. provides. Prenatal and Maternity Care. Before the 90's, if a pregnant woman didn't have medical insurance they were required to deliver at the county hospitals. I started my training at a county hospital in the mid 90's and thus I remember stories of how it “used to be”...deliveries in the hallways because it was so overcrowded. The NICUs (Neonatal Intensive Care Unit) packed with premature and sick infants because there was no prenatal care to be had. And then we decided that this type of care was intolerable and thus now all pregnant women without insurance are given MediCal and low and behold...the county delivery rooms are pretty quiet. The NICUs are empty. Women are getting prenatal care delivering at UCLA, Cedar-Sinai, whatever hospital they choose basically. Obstetrical mortality is lower; infant mortality is lower. The hospitals are happy because they're getting paid to attend to these patients. No where in LA is there a wait list to get prenatal care or overcrowded delivery rooms. You see, there's plenty of providers and hospitals to take care of these patients. The providers and hospitals are happy. The patients are healthy. Win win.