When the Healthcare Coverage Debate Comes Home to Roost

It was bound to happen sooner or later.

Those of us who are convicted will convict ourselves with the strength and, sometimes, the inflexibility of our beliefs.

In our efforts to 'convert' or 'convince,' those we love bear (at one time or another) the brunt of misguided proselytizing.

In other words, I was wrong, and it sucked. It won't be the first time, nor will it be the last.


Tonight the husband and I ate at a great little restaurant in Adams Morgan called Cashions.

We were very happy to see organic chicken and Eco Friendly Farm pork listed, but talk quickly veered off the topic of what we'd have to eat.

I'll apologize here to fellow diners elbow's length away, as a debate we had regarding consumer choice and coverage in the healthcare market got a bit more heated than my bowl of spicy squash soup.

The narrative that got us off to the races was this:

* Our patient has pain in a very specific spot below his last rib on the right side. This pain has been "annoying" and rates, at worst, a 1-2 on the 1-10 pain scale. Pain is aggravated with prolonged sitting. Patient is on no meds for this pain.

*Two separate visits/physical exams by a trusted internal med doc reveal no abnormalities. Sonogram reveals no abnormal findings. On first lab panel, liver enzymes were significantly elevated. On a followup panel, findings were well within normal ranges.

*When asked "what's wrong?," well-liked IM doc states something along the lines of "I don't see anything, but you know your body better than I do, what do you think it is?" Patient replies "something muscular?"

Now here's the kicker:

*Patient will be visiting same internal med doc in the near future. The patient has decided, pre-visit, that he/she will request additional diagnostic testing for phantom rib pain, which has caused no significant alterations to daily activities including vigorous exercise (running etc). Patient has noted increased pain during some runs, but has not discontinued activity due to pain.

Here's what got me going:

*Patient has determined that they will elect to request further imaging including CT and/or MRI just to make sure, especially if doc cannot provide a firm diagnosis.

*When asked if patient would make same selection of healthcare services if he/she was self-pay versus full (very nice) insurance coverage via employer 100% paid UHC plan, patient replied somewhere in the neighborhood of "hell no - I'd probably stop either before the sonogram or now - I'm not paying for it" (!!!!).

*Rationale for further testing included personal emotive rationalization of costs for exhaustive testing, even though further testing has not been medically indicated nor recommended by the physician to date (this may change during future exams or of course if symptoms/condition worsen). Comments included things like "well I'm not paying for it" and "I've paid into this plan for over four years."

When faced with actual cost realizations about how much further testing would 'really' cost versus how much the patient would see/be responsible for on a bill, patient was surprised, dismayed, and defensive.

All my fault, since the patient is my husband, and I failed to take into account that this 'teaching' opportunity would hit too close to home.

Here are the lessons:

* When patient is someone near and dear, carefully weigh value of 'debating' and 'promoting' education or your own personal agenda - those closest to you will (rightfully so) ALWAYS take this personally.

* Woe to those of us who forget that health decisions are always, always influenced by the personal - personal fears, personal CvB analyses, personal ability to pay or lack thereof, etc.

* My most important concern in this instance should have been what the patient was going through - what influenced him to consider options and how he makes his choices.

* Oh hell, he's my husband - my first concern is his health. The choices he makes are his. The costs and consequences are ours to bear.

*To thine own self be true: Examine why the issue raises your own hackles.

My motivation in discussing the need for patients to be educated consumers, COGNIZANT of the real monetary costs of their healthcare choices, actually grows from a strange sense of misplaced guilt.

After multiple ankle surgeries, for which I will NEVER bear the full burden of cost (thanks to managed care, without which I wouldn't have a working near-bionic billion dollar ankle), I am up walking and dancing barefoot at my sister-in-law's wedding, running half-triathlons and generally taking for granted the fact that I've received more excellent care than I can ever repay.

How can I give back to a system that literally saved my mobility? That allows me to enjoy things like a leisurely walk home without a cane? The fact that I can still wear 1/2 inch heels after being told I had less than a 10% chance of walking without a mobility aid?

The answer is simple: from the inside.

I'm not a doctor. I'm not a nurse. I'm not a counselor, or a physical therapist.

I am a manager. I am an innovator. I am a challenger of the status quo. I am a relationship builder. I am a person who calls my direct reports by their first names and worries about their families on the weekends.

What can I do to change the system? Get inside it. Make changes where I can. Continue to hope that improvements are possible. Proclaim that belief, and help others buy in.

The single most discouraging portion of our conversation tonight happened just after I'd realized I was arguing with my own demons, not the 'patient's.'

If I hadn't had insurance I wouldn't have had a great doc and a wonderful fixator and great followup care and the aqua therapy that allowed me to be up and weight bearing four months ahead of schedule.

The single most discouraging portion of our conversation tonight was when my husband looked me in the eye, after I apologized profusely for crossing the border of constructive conversation and personal empathy (veering dangerously close to 'preaching') and said:

"But I'm just one person. I can't do anything to change this."

And believed it.

Oh honey - people like us are the only ones who ever will.

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