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Adventures in low income health care.

June 19, 2012

There are definitely differences in the care one receives as a low income individual compared with care received when holding private insurance.  In the words of the charge nurse of the clinic I go to for primary care, “It’s a great program, but you have to be patient and persistent.”  I am fortunate to live in an area that has a comprehensive program of public health care for people who are not eligible for Medicaid yet have income below 150% of poverty level or 200% if one is disabled.  Under the Travis County Medical Access Program (MAP), people who qualify (like myself and my husband) receive primary care through a network of clinics, specialty care through the Brackenridge Specialty Clinic, and prescription drug coverage.  There are low copays for services.  For example, medications cost $5 to $14, doctor visits $10, hospitalization $25.  Many places have nothing of this kind to help people who cannot afford health insurance.  Of course like just about every other place else in the United States, if you have more income than this you are out of luck.  You either come up with cash, or receive no health care except in emergencies.  There’s no avenue for work up if you know or suspect something serious is brewing.  Even medications are out of reach for many people without health insurance.

So the program that covers my health care really is pretty generous compared to what I could get elsewhere.  I am grateful for it’s existence.  That said, it has been a challenge to adjust my expectations to match what is available to me compared to when I had health insurance.  Before, when I saw my primary care doctor, they could usually get me in the same day if I had a problem.  The office was quiet and pleasant and the wait minimal.  My doctor was kind and cared about me as a person.  If I needed to see a specialist, I called one up and made an appointment.  When I was hospitalized (a disturbingly frequent occurrence of late) my room had a door and it was relatively quiet.  The doctors wrote comprehensive comfort orders so I didn’t have to worry about whether they had written for pain medication.

Now, I plan for any doctor visit to take at least 2 hours.  I’m actually not sure why because the place doesn’t seem more crowded than a regular doctor’s office.  One difference is that after the doctor visit a nurse explains the plan and follow up.  I’ve been accustomed to just talking to the doctor about it and leaving.  You spend a fair amount of time waiting.  The doctor is not with you longer.  The doctor I was assigned to doesn’t even say goodbye, she just walks out of the room at a seemingly random moment.  I doubt this is representative of all the doctors in the clinics.  I just got the bad apple.  I will be changing doctors just haven’t figured out who to change to yet.

The last time I was in the hospital (my first hospitalization under this program), the care in the ER was excellent and compared favorably to my experience at other hospitals.  The accommodations when I stayed overnight did not.  I was in the “Chest Pain Unit,” an area for holding the overnight rule out MI population.  There were no rooms, just beds with curtains around them.  They did provide the usual bedside table and had TV.  That would have been ok, but all the overhead pages for the ER were piped in.  I have no idea why the nurses in the Chest Pain Unit need to know that Dr. So & So needs to report to crash bed 6.  These announcements were made every time a patient arrived in crash (the critical care section of the ER).  The hospital also plays Big Ben chimes every hour on the hour.  Personally I found it to be another disruption.  It was hard to sleep with my neighbor’s TV going all night.  I could also hear all the conversation at the nurses’ station.  I really missed my door and walls from my previous hospital.  Also meal service was not as nice.  The trend in hospitals has been to move to patients being able to order food from a menu and at the time they want it (during operating hours of the meal service).  This hospital is behind the curve.  No choices, no telling when it was coming.  Next time I need to take snacks and earplugs.

The doctor experience is really different in a teaching hospital.  The residents are inexperienced and tend to write orders sporadically as they realize they forgot something or were instructed by a higher resident or the attending to order something.  If your diagnosis is something off the beaten track you may be teaching them about it rather than the other way around.  Rounds with the team are done once a day.  It was almost comical watching the attending physician and 5 residents trying to squeeze into my cubby hole.  Later when I developed a migraine from all the stress, I discovered no pain medication had been ordered for me and since the discharge process was already in train it was not worth the trouble to try to get some.  And yes, like other things, the discharge process takes somewhat longer than with a private doctor.

Getting a specialist appointment is like pulling teeth.  When I first saw the primary care doctor, I was told a referral would be made for cardiology, but they had no idea how long it would be for an appointment.  I was supposed to wait for a scheduler to call me someday and tell me when my appointment was.  To illustrate how this process goes, my husband was referred to a specialist in late April.  He still has not heard from this mythical scheduler.  I was referred to cardiology at the same time.  I gave up waiting and went to the hospital for treatment.  I did not see a cardiologist then, but the doctor was able to get me the golden cardiology clinic appointment in 3 weeks.

The specialty clinic is fairly nice.  The waiting room isn’t crowded.  The clinic looks modern.  The 2 hour rule now stretches to 2 to 4 hours.  The last time I was there, I actually waited two hours in an exam room before being seen by a doctor.  I was chastised by a nurse for complaining that I was becoming extremely fatigued and she asked me if I had read the information that said clinic visits were 3 to 4 hours.  You are seen first by a resident who may or may not know much about your problem.  Then they come back with the attending and possibly the whole herd of residents.  My first visit the resident was nice but didn’t know much and asked me things like do I ever take a day off from my nitroglycerin to reduce my tolerance (NO, I like my coronary arteries to be open.) and do I think anxiety is my problem.  Though put delicately, that last scared me almost to a panic because anxiety or not I do have documented coronary artery spasms and my daily chest pain responds to cardiac meds.  I need treatment not a pat on the head and off to psychiatry you go.  Fortunately the attending was familiar with my condition and prescribed appropriate treatment (and no nitro holiday).  This last visit the resident was much more experienced and asked reasonable questions.  He put me at ease rather than scaring the crap out of me.

My favorite thing from this last trip to the specialty clinic was when I noted that the stickers with my name, birth date, doctor, etc. had a blank for an alias.  I’m thinking of getting one to maybe fit in a little better.  For some reason “Sparky” keeps coming to mind.  If you have suggestions, please comment.  Maybe we should have the first ever chronicconcerns contest.  We’ll have to find donors for prizes as I’m running a bit short right now.  I could send you my new chronicconcerns business cards (free from Vistaprint), but that’s not very exciting.  I will entertain suggestions for prize donors as well.  What do you think?

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