The Case of the Relatively Young Man

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?

Comments

[Surgeon in my Dreams]

I love your site, let me preface by stating that fact. I have learned from reading it.

I am always hesitant to make a comment that goes against what the author has written, but with some I read, it is either respond or "bust a gut".

The choices relatively young man made are not near as hard to believe when you have lived in a situation where you have to make tough choices.

You get down, maybe through your own fault or maybe not, and you just feel like no matter what you do, its all hopeless. You feel like no matter which decision you make, it will be the wrong one.

Who knows if he drank beer or smoked $5 cigarettes? When you've walked in his shoes, then maybe you judge the reasons for the risk he took.

If I have to choose between my blood pressure meds or my husbands pain meds....he is going to get his pain meds. His relief is immediate - my stroke or coronary based on percentages and my age will be some time in the future. For right now, I want to see relief on my husbands face.

Stupid choice? Who can decide that?

[Penny]

I like your idea for a doctors' scrip allowance. Though there's always the moral hazard: once people know you have $5K to hand out, they'll pressure you to spend it on them.

I'm not sure that the problem is the lack of guts to fix the problem. Nobody knows for sure what the solution is. Lots of people think they know, but it is unknowable at this point.

I'd like to see us have a national health care solution test period, when proposed solutions/systems are put into practice in states/regions of the country for say, 10 or 15 years.

At the end of the test period, results, both financial and health, are evaluated, and failed systems are abandoned and successful ones expanded. Eventually we'd end up with a nationwide working system.

Just because a system sounds logical, or good, or just, doesn't mean it will actaully work. Humans, and economics, are much more complicated with that.

[Michael Hebert]

Surgeon in my Dreams:

Thanks for responding.

Actually, I am aware that I overstated my case with the cigarrettes and the beer remark. I said that not because I believe he is doing that, but because I wanted to put the situation in its worst possible light so unsympathetic people would see that it is not only to the patient's advantage that we help him, it is to all of our advantages.

I have to stand by my statement that his hesitancy to pay for his treatment was wrong. His hospital stay already cost probably $15,000. He had no problem with that, because it was not an immediate cash outlay. But he put $15,000 of work at risk for the sake of $200 cash, and this is not a good situation. You know the old saying:

For want of a nail the horse was lost;
For want of a horse the rider was lost;
For want of a rider the message was lost;
For want of a message the battle was lost;
For want of a battle the war was lost.

Small problems lead to big problems. My point is not that this patient did anything wrong (though I personally think he did), it is that we cannot afford to let him make choices like this.

My judgment on him is a little harsh. If this kind of thing did not happen to me as often as it does, I might agree that it is unfair. But after seeing it almost on a weekly basis for 5 years you get to the point where you wonder if your life's work is nothing but a waste of time.

I must also point out that cost is no excuse. As I said, I changed him to a cheaper medication as soon as he asked. In fact, the med I used cost about $12. His fault was not that he didn't pony up the $200. It was that he chose to do nothing for 4 days.

I agree that medication can be horribly expensive but so is eating. This fellow was not starving. He figured out a way. We all have to figure out a way.

Remember, I took care of him for free. I would do it again, no problem. But we all have to walk on our own two feet, or ask for help. I would have helped him. I warned him the medication would be expensive and I was emphatic about that. He has to do SOMETHING. I can't do it all. That is my side of the story.

P.S.: If you ever have to choose between your BP medicine and your husband's pain medicine, CALL YOUR DOCTOR. Most doctors will switch you to a cheaper medicine or offer samples. There is usually something that can be done. But again, you have to ask for it.

Penny:
You are right, the weakness in my plan is that once the word is out about the allowance, people will try to take advantage of that. But I think this can be limited by excluding pain medication or chronic medications from the list.

I do think the problem is that no one wants to address national health care. HSAs, which I have recently ranted over, are the type of lilly-livered half-solutions we have been getting lately. There are still two many people opposed to universal health care for any progress to be made. I offered this partial solution only because bigger solutions are not in the pipeline.

I appreciate your comments.

[Cathy]

Boy Dr. Hebert I have to play devil's advocate with this one. Your stating things from your point of view that may have nothing to do with his situation.

Yes, there are people who cannot under any circumstances afford to pay 200.00 for prescriptions. My take is that he probably waited the 4 days to go to the pharmacy because maybe that was when he would get a paycheck, or the earliest a friend or family member would let him borrow money. I doubt he knew they would be THAT expensive and when he found that out it was more than he had in his pocket I think if he had that much money in his pocket, rather than tell the pharmacist he didn't, he would have paid and gotten them.

He didn't tell you because he was to embarrassed for you to know. So he waited and went at his earliest possible time. I don't see that it had anything to do with deliberately waiting to see if he got worse and then he would just return to the ER, because he didn't.

There are many people, for thousands of reasons, who cannot borrow any money. We would really have to know his entire situation to know if that was an option.

I think he wanted to do what you said he needed done. He didn't just deliberately wait for 4 days to do so, because that really makes no sense. If he waited that long and wasn't yet sick then why would he go to get them at all?

And, it's that sex (M) and age group who would be less likely to say to a doctor (another man) I have no money and cannot get this medicine.

But that is just my opinion and I am more often wrong than not...:)

[Flea]

Cathy beat me to it. Embarrassment could explain his not scraping up the $200.

BTW, I understand your reasoning, but you COULD have put him on something cheap, couldn't you?

best,

Flea

[L]

"I got a call from the pharmacy about Relatively Young Man."

It was the pharmacist who knew to call you and ask for less expensive drugs. If the young man hadn't gone to the pharmacy, he wouldn't have known that this option exists. So at least he got this far.

"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."

Even those of us who are experienced patients are often baffled by the health care system - knowing what an insurer will and won't cover, what drug choices we may have, how much things cost, trying to understand what a doctor is saying, etc. For someone like RYMan who had just landed unexpectedly in Medical Care World, it would be even more baffling.

And in his defense, he may not have known how you would react to a request for a cheaper drug. Or he may have thought that another drug wasn't an option. Or he may already have been hounded while in the hospital by the billing department, that he had this huge bill coming, and RYMan just couldn't face another medical expense, particularly since he was feeling better. Or his rent may have been due.

You are right, it is bad for society to have RYMen and RYWomen, for that matter, walking around and having no health coverage. Perhaps the new effort in Massachusetts, to require everyone in that state to have insurance, will finally address this issue, though it remains to be seen how that will all play out.

On a related matter, tell people to check out Walmart to fill their prescriptions. Whenever I've checked, they've got the lowest drug prices, much better than CVS or the grocery store pharmacies.

[ripple of hope (difficultpt)]

I'm irritated that he didn't have health insurance. I have health insurance through my employer, but if I didn't, I'd be SOL. Why? Because of previous illnesses, I cannot get private health insurance (I know this because I was declined). However, I make too much money to qualify for Basic Health. In fact, it doesn't matter how much money I make, I'll make too much (combined with child support/separate maint).

Normally, a person in my position could get private insurance, but when you can't, where are you left? You fall through the cracks . . . Perhaps he was in this situation, and it was pride that kept him from calling earlier. He isn't necessarily spending his money on unhealty alternatives--maybe he has none. Who knows . . . but there are definitely huge flaws in the system.

There should be some type of health insurance available for everyone.

[Michael Hebert]

Flea, Cathy:
I probably should have put him on something cheaper. If I had put him on something cheaper, like Bactrim, and he had come back to the ER in a week, whose fault would it have been then?

Anyway, I thought I was clear about the price. I did warn him, and more than once.

I find it frustrating that doctoring often requires clarivoyance. Not only do I have to answer the questions the patient asks, I have to anticipate the questions he might have asked but didn't, and the problems he says he understands but really doesn't. I don't think anyone is so good that he or she does that all the time, or even half the time.

I hope I don't have to say that the obvious problem here is not me or him but the fact that there are so many uninsured patients in this country.

[Cathy]

Dr. Hebert, I don't think anyone would expect you to know these things. It would be stupid for someone to think doctors should also be mind readers with everything else they have going on. I was just pointing out the reason's that I thought he might have waited those 4 days.

The real problem, as you say, is that their are so many people without ins. and who aren't likely to get any. When I left work and was waiting on my disability to be approved, ins. was a BIG problem. HIPAA states that since I lost my ins. through our group policy at work, through no fault of my own, that I had to be offered a plan, regardless of my pre-existing conditions. I was offered a plan but it was undoable. For a horrible policy with 8,000.00 deductable and 20% co-pay and a 2,500.00 anual limit on prescriptions it would have cost me over 1,100.00 a month for just a single person plan. I had previously been paying 60.00 a month through my plan at work. My prescriptions were over 1,000.00 per month. Anyone could see this plan would not work for me. But, I was denied coverage by every other company due to pre-existing conditions. Seems kind of strange that you can only get ins. if you are not sick, have never been sick and don't plan on ever getting sick. Only the very healthy people can get ins. Am I the only person this seems strange too?

[Deirdre]

I live in Canada where medicare is free but we still pay for medication. My 18 year old lives in another town and works two parttime jobs. There is no way she could come up with $200 for drugs and she doesn't smoke, drink or have cable.

Part of the problem is people live to their income. Cancelling the cable and not smoking for a month would NOT get the $200.00 into his pocket when he needs it. Low income people don't have $200.00 in disposable income even if they scrounged from friends and family.

[CardioNP]

I see patients failing to fill discharge scripts all the time. I work at the VA. Frequently have patients discharged from the local private institutions (where they were taken by 911 for their MIs) who wait a couple days, then bring in their rx's and want them filled by the VA.
One such patient, who was not so young, decided to wait over the weekend prior to requesting his Plavix be filled at the VA, unfortunately before he got to the VA, he had restenosis of his new LAD stents he had another MI and called 911 again.
Not so young patient, in his efforts to save a few bucks , cost the system a whole lot more money.

[Figmo]

Thank God for the VA. I get Lantos, Glucophage, Glucotrol and Simvastatin at no cost. I have private, employer provided health insurance but the co-pays are outragious. The VA bills my insurance but doesn't charge me any co-pays. Now can any of you medicos tell me why I have type II diabetes when my BMI is 22.5, I eat moderately and exercise everyday? Actually, I know why, it is some family quirk as my 16 year old, 5 foot, 85 pound daughter has high blood sugars and is on medication also.

[anonymous]

I can't presume to speak for RYM, but I know I would have a hard time coming up with $200 cash for medication, on top of a co-pay I'd be facing for a hospital stay.

I have insurance. I grew up in a professional white-collar household, have a college degree and own my home. But I am in a low-paying field (library science) and it's not uncommon for me to have almost no money left after the bills are paid.

I would never in a gazillion years confess to a physician that I didn't have $200 for antibiotics. Why? Because I don't want to be labeled as "poor" or as someone who can't afford to pay her bills. It's humiliating, especially when you are ostensibly middle class and have all the right trappings and are presumed to be on the same economic level as other white-collar, college-educated home-owning citizens. People don't want to believe how little I earn, or else they assume I am somehow wasting my money on extras such as expensive cars or exotic vacations. I'm not.

Don't get me wrong, I genuinely love what I do, I knew the pay was low when I chose this field and I'm not all that materialistic. I have enough to get by and that's fine with me.

But I don't want to be pinned with some label that will follow me around through the health care system for the rest of my life. People can be extremely judgmental of those who don't have much money, and it's demeaning and humiliating. No thanks, I don't need it. If that sounds prideful, so be it.

That said, I would have found a way to scrape up the $200 - probably taken it out of my bank account and then scrimped for the next few months to come up with the hospital co-pay.

I think a lot of people share my reality, but for the most part we are silent about it.

[Michael Hebert]

anonymous:
I appreciate your sitution, but I wish patients would always tell me if they can't afford the medication. I don't care what your reasons are. Most people don't understand that on my side of the fence I hear every story imaginable. Nothing fazes me. I wouldn't think twice, but not all physicians are like me and I understand that is another barrier.

Keep in mind that an antibiotic treatment like this is a one-shot deal. Forget about your hospital co-pay, get the medicine first. Hospitals and doctors are used to waiting for payment.

Anyway, that is why I am in favor of universal health care. What we have in this country is blatantly unfair to the poor. Unfortunately, history says the poor are only heard from when they get hold of the guillotines.

By the way -- stick with the libraries. I would rather be there than in an exam room any day. I worked for a year at the rare books library at the University of Virginia, and it was one of the best jobs I ever had. Our collection was astronomical -- among the orginal manuscripts wwe had were the "Leaves of Grass," "The Sound and the Fury," and the "Red Badge of Courage," to name a few. My favorite was a complete collection of first-edition Dickens novels in their original format, which was 39-page pamphlets pubished in serial form.

[anonymous]

Thanks for the response, Dr. Hebert.

Actually, people who are genuinely poor can always qualify for Medicaid. It's the people who are on the borderline or slightly above who can really be at risk - people like me who make too much to qualify for any kind of assistance and who are employed and have health insurance - but for whom an emergency medical bill can be difficult to pay. Even if it's a one-time deal, it's still an unplanned cash expense.

I personally would find a way to pay it, hardship notwithstanding. It would be easier if the bill was $2,000; that's considerably more money and it's expected that some patients will have difficulty paying it. But $200? I would feel pathetic telling any doctor, even one as nice as you, that $200 is a hardship.

[Michael Hebert]

anonymous:
Medicaid can be ridiculously hard to get. You would be surprised. I know patients who got $500 a month in disabilitiy payments ($6000 a year, far below the poverty level) who have been told that they make too much money for Medicaid.

The weakness in our healthcare system is that there are so many gaps and loopholes in coverage. You look at all the exceptions and rules and deductibles in their plans and you wonder if they want their customers to get health care at all. Honestly, I don't think they do. I think every time an insured patient has a massive heart attack and dies at home someone in the insurance biz cheers because it means they get to keep all the premium money.

That is why I think the medical profession will ultimately come out in top in the struggle over health care. In the end, you doctor wants you to get more medical care and your insurance company wants you to get less. Who is the pubic going to trust, and in the end, support?

[110/70]

What I take from your story, Dr. Hebert, is not that there are people without health insurance but that everyone in this country – without exception – is already insured in the sense that they will receive treatment in the case of a medical emergency. We already have universal health insurance!

[mca]

No we don't have universal health insurance. There is certainly more to medical care than treating you only when you are in a life or death situation.

[Grady]

I was really struck by your story, but more by the thought process you went through. I think you got it exactly right when you said that medicine will have to change to accomodate the RYMs of the world. It's clear that even though he had options, he chose none, despite the risks, so what that leaves is two things: Leave him to make poor decisions by himself, or make the decisions for him. I don't like the first option any more than you do, but the second option is pretty clearly leading to universal health care. In this case, it's not just subsidized care up to a point, but even to the point of paying for $200 antibiotics when a $12 may work as well.

[Jill]

Wow! I had a patient in the pharmacy I was covering for the weekend with a story remarkably like that one. It was two years ago or so, though, out in Slidell. He could only buy half the prescription, even after it was changed to something cheaper, and even that he could only afford because I gave him $10.

He had no one else to turn to for a loan.