Thursday, April 9, 2009

"You think YOU'VE got a headache!"...

You know, as the conversation about America's heatlhcare "system" goes on, I'm struck by some of the standards of practice that we've all engaged in. When I put "system" in quotes, I mean to imply that we don't have a system - certainly one of the criticisms of health care in America is that there is little coordination of care among different providers, different settings ... let me tell you a typical story about that.

This week, I saw a young man in our Community Health Center. He's unemployed, and living with his father. He is uninsured, and we are able to see him on a sliding scale basis, charging him "according to his ability to pay." He tells me that he is here because he had a prescription from an emergency room visit a few months ago, which he'd like to have filled in our pharmacy.

I spent some time getting to know a bit about him, and reviewed the history about his headache. He notes that this seems to be worse when he's around dust. Some further conversation and examination confirms my impression that he has an allergic condition. No big deal; I know how to treat that.

Oh, but what about that prescription? He was seen in an Emergency Department at a well-respected hospital in Seattle. And, he tells me that he had a sinus infection. I just got the notes to review...

So, with a story similar to what he related to me, the ED physician did the following tests:
  • CBC with differential
  • Complete metabolic panel
  • Urinalysis
  • Blood culture
  • Sedimentation rate
  • C-reactive protein
  • amylase and lipase
  • CT-scan of his head
  • Total cost: ???

Gosh, am I just a bad doctor? I didn't even consider any of those tests! In fact, I'm not even smart enough to figure out how ordering amylase and lipase levels, often used to evaluate abdominal pain due to pancreatitis, would relate to the assessment of a patient with a headache! I guess I need to watch "House" more often!

And, the prescription? Well, it was for:

  • Augmentin - an antibiotic [approx retail price from = $145.99]
  • Nexium - a proton pump inhibitor, to reduce stomach acid [ARP = $176.01]
  • Beconase AQ - a steroid nasal spray [ARP = $149.32]
  • Fiorinal - a migraine headache medicine [ARP = ~$45]
  • Total cost: $516.32

So, this uninsured young man saw me for a few minutes. I charged him $20 for the visit, and our pharmacy charged him $15 for the nasal spray.

What do you think that Emergency Department visit cost? All those tests, the highly-trained ED physician? Am I just an incompetent quack, because I have the confidence in my own skills to make a diagnosis and begin treatment without any of that stuff? After all, I just listened, mostly...

As our Administration wrestles with healthcare reform, this case illustrates too much about what's wrong with our "system"... overtesting, overtreating, overutilization. Money spent in the ED which could have been used to address the healthcare needs of many more in the primary care setting, including immunizing kids, providing dental care, managing chronic disease. Misaligned incentives and muddled motivations.

I wonder how his headache is? I'm getting one just thinking about it all...

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