The Small Costs

by Danielle Ofri
New York Times

Recently a few of my colleagues were sitting together and one asked if any of us had ever given money to a patient. There was an awkward pause, and then the stories starting coming out — a few dollars for a co-pay, or to help a frail patient take a cab instead of a bus; a bag of food or an extra meal. “How could I not,” one doctor said, “when my patient’s immediate need could be solved by the small change in my coat pocket?”

A physician recently wrote in JAMA about giving a patient $30 to help pay for a medication after a two-hour phone battle with the insurance company came to naught. He was cited by his institution for unprofessional behavior, but was also deluged with letters from doctors and nurses who have been in the same position and done the same thing.

We hear daily about “health care costs,” a lumbering behemoth that dominates the news and the economy. But it is the smaller amounts, literally the pocket money, that often has the most profound and palpable effect on the concrete currency of health.

Caregivers on the front lines fully recognize that giving patients a few dollars isn’t ultimately the way to solve the problems of society. But the starkness of our patients’ immediate needs are hard to ignore.

One of my patients with diabetes recently lost her food stamps benefits, and her blood sugar hurtled out of control. “Brown rice costs so much more than white rice,” she told me. “Potatoes are cheaper than fruits and vegetables.”

Another patient of mine has been living on unemployment after she was let go from a 30-year career in personnel management. She was savvy enough to get her mammogram and Pap smear before she lost her insurance. But now it is time for a colonoscopy and her unemployment benefits have run out. Even the modest co-pay at a public hospital gives her pause. She is trying to ration her dollars for healthy food to keep her cholesterol and weight down. There isn’t enough in her budget for a healthy diet and for cancer prevention.

Last week one of my patients was diagnosed with a urinary tract infection. When I gave her the antibiotic prescription, the first thing she asked me was how much it cost. I assured her it was a generic antibiotic, one of the oldest, most basic antibiotics out there, not to worry. It turned out to be $50 at her pharmacy, and she called me back to ask me if the medication was really necessary.

Even though overall health care costs have been falling slightly, and some aspects of the economy appear to be improving, economic realities are playing an increasing role in the day-to-day health of many patients. The dollar amounts in question are usually small — bundled together they would hardly rise to a rounding error of a distant decimal of “health care costs.” The impact, however, is anything but small. Medications skipped, antibiotics delayed, procedures avoided, diet skimped — the morbidities rack up quickly.

A recent study in Health Affairs confirmed what most physicians and nurses see in their daily practice — lack of small amounts of money wreaks outsize damage on health. This particular analysis showed that in low-income neighborhoods there was a 27 percent increase in hospital admission for hypoglycemia, or low blood sugar, at the end of the month compared with the beginning of the month.

This end-of-the-month disparity, unsurprisingly, was not noted in high-income neighborhoods, where households do not run out of money and food at the end of the month.

From a medical point-of-view it is immensely frustrating — huge medical efforts dismantled by basic lacks. From a humanistic point-of-view it is heartbreaking and angering — how is it possible in this richest of countries that so many of our citizens go hungry? But from an economic point-of-view, it is simply insanity. A single hospital admission surpasses $10,000 before a patient so much as hiccups. A week of food to make it to the end of the month? Probably less than the IV tubing and dextrose solution.

Unemployment benefits and the food stamp program are in the Congressional cross hairs, with partisan arguments raging about budget deficits, fiscal restraint, entitlement fraud and economic recovery indicators. Missing in the discussion are the medical repercussions of the penny-wise-pound-foolish cuts to these programs.

Those who are economically struggling already shoulder the lion’s share of illness in American society. Our society and its policies should not make people sicker.   (from the  New York Times)