Andrew Perry, MD
I knew I had seen him before. Or was it that he looked like one of the actors from "The Office"? Either way, he did not look very happy, laying there on the stretcher in the emergency department.
"I went into atrial fibrillation [Afib] again," he said.
He ran out of medication about a month ago. The medication was too expensive for him. While at work today, he felt the palpitations return accompanied by shortness of breath. He came to the ER and had Afib with rapid ventricular response. He was getting a diltiazem infusion and would need to be admitted.
"It's not that I don't have a job, doc," he told me, "It's that my job doesn't pay me enough to cover these medications."
What kind of job does this guy have? I wondered. This is a familiar story: a patient with a chronic illness shows up in the emergency department for issues that could have been prevented if he or she had access to affordable medications. This guy probably works part-time at a fast food chain or something like that, I thought.
"Where do you work?" I asked him.
"Here in the hospital [food services]," was the reply. "I'm actually a really good chef," he said, "but nobody needs that skill anymore."
Unwillingness to provide my patient's medications resulted in an escalation of care, from stable outpatient management to emergency services and hospital admission.
This story highlights how employers and insurers attempt to "pass the buck" of healthcare costs to someone else, resulting in an overall increased cost of care. Since we, as a country, have decided we are morally obligated to provide emergency care, eventually these costs will come back to us -- the buck stops here.
Is it financially advantageous for the hospital (acting as both employer and healthcare provider) to behave this way? If we assume that the hospital charged him what it charges the Centers for Medicare & Medicaid Services, he was charged between $14,057 and $23,509 for the admission (For DRGs with "cardiac arrhythmia." Information available here). If the patient had Medicare, the hospital would receive between $3,360 and $8,133. Compare that to the estimated monthly cost of his medications: $430 a month (for diltiazem ER and apixaban, from GoodRx). If he had been prescribed warfarin instead of apixaban, his monthly cost would be $13 a month.
How much will the hospital recoup for this admission? Probably not much. This will become part of the hospital's sunk costs, and the hospital will receive some small reimbursement for being a safety-net hospital. By not providing the medications he needed a month ago, the hospital will spend more money on a hospital admission that could have been avoided.
This is not a unique story, but one that plays out every day in hospitals across the country. Have you noticed ironic disparities like this in your daily practice, too?
Andrew Perry, MD, is a resident physician at Barnes-Jewish Hospital and Washington University School of Medicine in St. Louis.