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Connecting health insurance to quality of medical care

Sarah Zarbock, PA-C

Sarah Zarbock, PA-C, is the editor in chief of JAAPA.

My husband entered my home office looking somewhat stunned. What he said took me completely by surprise. “I’ve been rejected by two companies for health coverage.” “You’ve what?” I asked. “I’ve been turned down because of my knee replacement. Not only that, but your monthly premium is almost double because you take some medications.” I actually laughed out loud. “You’re kidding, right?” I said in disbelief. He wasn’t.

I’ll spare you the details of how we had been struggling to get health care coverage after our COBRA coverage ran out. After a month of frustration, disbelief, and mounting anxiety over possibly having to pay a staggering amount in monthly premiums, we did finally get coverage, thanks to a new AAPA member benefit.*

For that month, though, and for the first time in my adult life, I had no health insurance and had become one of the 47 million Americans in what felt like a sinking boat. I became anxious just driving to the grocery store, worrying that I might be involved in an accident, taken to the local hospital, and required to pay out-of-pocket the entire cost of my care.

This was an incredibly eye-opening experience for me, certainly one that I never anticipated. I felt ashamed, as if I had done something wrong or irresponsible. I was angry at the health insurance system, and I couldn’t help wondering if this was how so many Americans, perhaps through no fault of their own, felt about themselves?

More importantly, was there something about my experience that was relevant to PA practice? Several questions came to mind. Does patients’ health insurance status relate to the care they receive? Does their ability (or lack of ability) to pay influence their care? Should providers know about a patient’s insurance coverage and take this into consideration when developing a plan of care?

PAs surely know that incredible disparities exist in this country in the ability to have access to and pay for health care. It’s naïve to believe that all patients get the care they need from providers who, in essence, wear a blindfold and act without bias or prejudice. Of the many factors that impact delivery of care, ability to pay is probably at the top of the list. Let’s face it. There are times when better care is given to those who can pay for it—but how many, and to what degree? Does it necessarily follow that those with better health insurance receive better care—or worse, that those with poor or no insurance receive poorer care?

Consider the following scenario. Mary is an 11-year-old girl who has frequent exacerbations of asthma. Her mother brings her to the clinic because the symptoms are becoming increasingly severe. Your assessment determines that Mary needs a change in her therapy. Her new regimen requires additional medication and home monitoring with a flow meter. Stop for a moment. Do you routinely consider the cost of your treatment recommendations, factoring in the patient’s ability to pay? Is it your responsibility to determine if, in fact, the patient can afford the treatment? Is asking Mary’s mother if she can pay for the recommended medication part of your holistic approach to caring for patients, or is that an intrusive and inappropriate question? Are you obligated to find alternative solutions if the mother says she can’t pay? Is a parent “noncompliant” if she doesn’t fill all the prescriptions because she simply can’t afford them? Is the possible bottom line that Mary may get “second-best” care—you get what you (can) pay for?

Another issue is whether knowing something about a patient’s insurance coverage as part of your evaluation and treatment plan serves a positive purpose. If you knew that Mary’s mother might not be able to pay, would you, as a caring provider, automatically adjust your treatment recommendations, even if the adjusted recommendations were not your first choice? I can see ethical red flags going up all over the place in my head. Shouldn’t health care providers be just as blind to a patient’s financial status as Lady Justice is to the determination of innocence or guilt?

How accurate would we be in identifying patients we believe have good insurance coverage from those who do not? I cringe to think of the criteria we might use to make this distinction. How many times would we be wrong, unconsciously connecting what we think our patients can pay for to the type and quality of care we give them?

The health care system in this country is severely broken and, as you’ve no doubt noticed, I’ve asked more questions than I’ve answered. But I also believe that PAs must examine their own beliefs and values about the care that they provide in the context of the financial realities of the patients they serve. It’s said that you cannot know a man until you’ve walked a mile in his shoes. Try on the shoes of someone who has no health insurance and see how it feels. It definitely changed my perspective. I hope you will examine how it might change yours. JAAPA

*AAPA members now can receive savings up to 40% on health insurance, life insurance, disability insurance, and more. For information, visit the AAPA Health Insurance Programs at www.aapa.miquotes.com/home.aspx or call (888) 450-3040.