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Ideally, all patients should receive the same oncology care, regardless of their ability to pay. The reality is often different, as this fellow can attest.
As fellows, we have all encountered uninsured
patients in either the hospital or the clinic setting.
Depending on the type of practice where you are
training (eg, private vs university, urban vs rural),
there will be a different proportion of patients who
lack insurance coverage. According to the Kaiser Commission
on Medicaid and the Uninsured, in 2009 there were 50 million
people in the United States under the age of 65 who lacked
health insurance. In many parts of the country, the stereotype
of the uninsured homeless patient has been replaced by
uninsured working families, who now make up more than
three-fourths of the uninsured population. The increase in
uninsured patients crosses age and ethnic boundaries and
affects their health because they are unable to receive both
the preventive and therapeutic care they need. In the case of
our patients, the need both emotionally and financially will be
high if they have a new diagnosis of cancer.
Unfortunately, the number of uninsured patients is
increasing at a time when the cost of cancer care continues
to rise. According to the National Cancer Institute, in 2006
cancer care accounted for an estimated $104.1 billion
in medical care expenditures in the United States. As we
develop advanced molecularly targeted therapies, this
number continues to rise. To an individual patient, there
is variability in the cost of cancer therapy, but when you
consider the cost of chemotherapy, surgery, radiation, and
supportive medications, it’s easy to reach tens of thousands
of dollars per treatment regimen. For all but the wealthiest
patients, this becomes cost prohibitive without insurance
coverage or another means of financial support.
As medical students and residents, we often are able to
defer insurance status issues to a team of support staff,
such as social workers and case managers. As we transition
to attending positions, the issues of insurance coverage
become increasingly apparent and important to understand
because of the potential interference in our ability to
provide excellent care. By understanding the unique
challenges of the uninsured and the resources available to
them it is—in most cases—possible to provide them with
the same excellent care as their insured counterparts.
Unique Challenges of the Uninsured
Throughout my fellowship, one of the main observations
was the similar challenges that are faced by patients
with cancer. Patients of every age, socioeconomic status,
religion, gender, and insurance status are subject to
the same disappointments and fears that accompany a
cancer diagnosis. In addition to similar human emotions,
uninsured patients have an additional set of worries that
is unique to this population. An example that has left a
lasting impression on me during training was a middle-aged
patient who was battling advanced pancreatic cancer.
Her poor prognosis and declining health were obvious to
me, the attending physician, the patient, and her family
as she progressed through treatment. As we aggressively
treated her symptoms of pain, nausea, and weight loss, we
found that we could not treat her biggest worry: losing her
insurance if she was forced to stop working. Despite her
symptoms, she continued to work 2 jobs in order to pay for
medications and maintain her insurance for her family as
she reached the end of her life. For uninsured patients, in
addition to the obvious stresses of a cancer diagnosis and
the effects of therapy, they are burdened with bills that may
be difficult or impossible to pay.
Many patients may feel embarrassed or self-conscious
about the fact that they cannot afford their medications.
For example, while rotating through my gastrointestinal
oncology clinic, I had a patient with locally advanced rectal
cancer undergoing neoadjuvant treatment with concurrent
capecitabine and radiation. Despite extensively educating
this patient on the importance of compliance with twicedaily
capecitabine, he consistently missed doses. As I
discussed the case with my attending, I was frustrated
and angry at this patient, as I felt he had a potentially
curable cancer but was compromising his care by not
complying with his medications. My attending was able
to further explore why he was noncompliant, and the true reason was that he was forced to choose between paying
for his medications or food for his family. Because he
was underinsured, he could not afford his medications
and therefore was rationing them by taking them every
other day. He was too embarrassed to admit that he
did not have enough money and was therefore willing
to compromise his care. This situation could have been
avoided with better communication with the patient. As
fellows, we may sometimes feel unequipped to deal with
these treatment-cost issues and may avoid asking our
patients if they need financial help.
Utilizing Resources
As insurance coverage becomes increasingly more complex,
we have all learned that some of our best allies in the
hospital and clinic are our social workers. As fellows, many
times the responsibility falls on us as the junior members
of the team to communicate with the social workers to
ensure that the patient has adequate insurance. There
are services through government agencies, the American
Cancer Society, drug companies, private funds, and other
organizations to help our uninsured patients. Utilizing
these resources can require patience, time, and paperwork,
all of which can be made easier if you have a good social
worker helping you through the process.
Another unique barrier I have encountered in
the uninsured patient is the challenge of adequate
transportation. Cancer care requires frequent physician
visits, which can be as often as every day if a patient
is receiving radiation therapy. It is easy to view missed
appointments and cancellations as irresponsible and
noncompliant, but transportation can be expensive and
the patients may need assistance simply getting to their
appointments. Again, a social worker or case manager
can usually help find a community or hospital resource to
provide this essential service.
Patient Care and Insurance Status
In my experience as a fellow, I have been fortunate enough
to be surrounded by physicians who provide excellent
care regardless of a patient’s ability to pay. I am idealistic
enough to believe that the treatment plan of an uninsured
patient should be of the highest quality and equal to that
of his or her insured counterpart. I am realistic enough,
however, to know that in today’s healthcare environment
there are limitations to what a hospital or clinic can
provide patients who do not have
insurance. In my experience, if a
patient cannot receive treatment
due to inability to pay despite all
the resources available, we refer to
the local county hospital, which is
able to treat the patient at no cost.
While this may feel like you are
abandoning him or her, ultimately
the goal is to provide the therapy our patients need and it
may not be possible depending on where you work.
In the United States, we are fortunate that, in most areas,
offering substandard oncologic care solely due to lack of
insurance is not acceptable. We have clinics and hospitals
that are state and federally funded to help patients who
do not have insurance. Unfortunately, even with these
services, an uninsured patient’s care may be negatively
affected in many ways if they cannot access the care they
need. Even with free care, there can be significant difficulty
in transporting the patient to clinics, which may be a great
distance from his or her home, and treatment delays that
plague many county healthcare systems. If the number of
uninsured patients continues to increase, there is no doubt
that these systems will be flooded and the challenges to
provide adequate healthcare will be magnified.
The Future of Insurance and Oncologic Care
In this depressed economic environment, there is no doubt
that the number of uninsured and underinsured patients
may increase. President Obama has made dramatic changes
to our healthcare system in the Affordable Care Act of 2010,
and the implications of this legislation are still premature.
The hope is that there will be more insurance coverage for
those Americans who really need it to get the care that
they deserve. In addition to providing insurance coverage
to a wider population, it will demand that our healthcare
system become more evidence-based, efficient, and cost-effective.
As this legislation unfolds, there will be a need
to balance the financial sustainability of our healthcare
system with the growing needs of our patients in the clinic.
As oncologists in training, we rigorously study treatment
guidelines and strive to be evidence-based physicians who
offer the highest standard of care. In today’s healthcare
environment, it will be important to also be aware of the
resources available to help navigate the system to actually
deliver this therapy to our patients. When we graduate
fellowship, there will be many opportunities to work in
different environments, from private practice to academic
centers, which may offer a range of resources to help you
provide the care you have trained for. In my opinion, that
is one of the many factors to consider as we take the next
step to becoming an attending physician.
Sheetal M. Kircher, MD, is currently finishing her oncology fellowship at Northwestern University in Chicago, IL.
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