Annals of Medicine: Limping Toward Healthcare Reform

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By Dr. Robert C. Reiser

After voting to deny health insurance to millions of Americans or shut the government down the U.S. House of Representatives took the rest of the weekend off. I did not take the weekend off. I spent the weekend caring for the uninsured of Northern Virginia. I do this a lot. I work in a hospital in Central Virginia designated to receive federal funds for providing care to uninsured patients (a Disproportionate Share Hospital or DSH in our lingo), so those uninsured patients are funneled to us from the affluent Northern Virginia suburbs among other places.

It may seem strange, inefficient and even unsafe to travel 85 miles from Manassas to Charlottesville for emergency care, passing several hospitals on the way, but that is the system. The patients seem grateful for the care and as a teaching physician I am grateful for the broader range of pathological conditions brought to our hospital from far and wide.

I saw a young man from the D.C. suburbs recently. He spoke only Spanish and had no health insurance. He had had a swollen knee for several weeks. There was no history of trauma and no other medical conditions such as gout or arthritis. He had no pain and no fevers, no rashes. He had been seen in a local Northern Virginia ER that provided him with a referral to a community orthopedic doctor for work up and treatment of his puzzling swollen knee. The orthopedist examined the patient and decided a rather costly work-up was needed to figure out the problem. At this point, in order to do the patient a favor and help him avoid a big bill, he recommended the patient go to my ER for free care. At least that’s how the patient relayed the tale to us. Sounds about right to me.

I was pretty sure the patient had Lyme arthritis, a somewhat common complication of untreated Lyme disease, but there were some atypical features. Most Lyme arthritis is quite painful and usually red and hot over the joint but this knee, though massively swollen, was not very warm or red and the patient could walk with only a slight limp.

I consulted our orthopedic group, who took a keen interest in this unusual presentation. Blood work was ordered to rule out early rheumatoid arthritis or other uncommon forms of arthritis. Lyme titers were sent and a needle was inserted into the knee to obtain a sample of the fluid for analysis for bacterial infection. Bacterial infection of a knee joint, a so-called septic knee, can destroy the joint very quickly.

None of these studies was diagnostic; nothing was definitive or characteristic of any one disease. Could this be cancer? It was time for the big gun, time to send the patient to the “donut of truth”—the MRI scanner.

This entire extensive, expensive and potentially lifesaving workup was performed in the space of an afternoon and evening in a busy and crowded ER while hundreds of other patients were simultaneously being evaluated and treated.

A quiet and overlooked revolution has occurred in the ERs, doctors’ offices and hospitals of America. Fifteen years ago this work up would have taken weeks to organize as an outpatient, requiring multiple office visits, outside lab blood draws and trips to X-ray facilities and would have been beyond the reach of this patient’s resources. Alternatively the patient would have been hospitalized for days to weeks to complete the workup. It would never have been expected in an ER setting. Now we are tasked with performing these extensive diagnostic workups in the ER routinely, and with good reason. It is more cost-effective to reach diagnostic certainty before hospitalization, rather than admit patients to inpatient beds for the same resource-intensive workup in a more expensive setting.

The ER has become more than just the expected safety net in the U.S. healthcare system; it has become the major diagnostic unit, the place where the most expensive decision in medicine is made: whether to admit to the hospital for therapy or discharge to outpatient management?

On January 1 the federal DSH payment system that supports the hospitals that provide this kind of service to the poor will be phased out. That’s OK. The Affordable Care Act’s expansion of Medicaid (a state and federally funded insurance program for the poorest Americans) is designed to cover the cost of caring for low-income patients who need lifesaving care and is supposed to replace the DSH system. Unfortunately many states including Virginia are refusing to accept federal funds to expand Medicaid to cover more poor Americans due to partisan politics. DSH is going away regardless, so there will essentially be nowhere for poor uninsured patients to go in Virginia to receive subsidized health care. I think the richest nation in the world ought to do better.

My patient was lucky. It was not cancer; it was an unusual presentation of Lyme arthritis. He got a 30-day prescription for amoxicillin. He was financially screened and his medical bills were prorated to a level he could afford. I wonder how much longer I will be working in a system that allows me to do this for all comers, regardless of their ability to pay.

Thirty days of Amoxicillin—$8. Ruling out cancer in a young person? Priceless. Congress, are you listening?