During our physician assistant (PA) training, we learn about the full spectrum of medications available for treating disease and study how to assess what is first-line, second-line, and so on. We review which tests are considered to be “gold standard” and become adept at selecting those on paper so we pass our certification examination and become licensed to practice medicine. What is not taught to us, however, is what to do when patients cannot afford their medical care.
When I began practicing in primary care 10 years ago, I was working with a patient population that was well insured; I could order “gold standard” tests and first-line medications for most. I became good at relying on these top-tier options for treating my patients. I was able to ask patients to come back routinely for follow-up and could count on them showing up for their appointments. Blood tests, imaging studies, and brand-name medications were all within the realm of possibility. Even when an insurance formulary limited choices, an appropriate alternative selection usually was available and caused but a hiccup in the process of achieving wellness for each patient. Yes, there were some challenges, but those were the exception, not the rule.
A few years ago, I changed clinical settings to work in a medically underserved area. Even before PA school, I had long desired to work with the uninsured and underserved populations, and this was my opportunity. I was thrilled to be able to be the source of care for those who may not otherwise have any, and I was idealistic in my goals for my patient interactions.
In this new setting, I was suddenly unable to order those gold standard tests. Patients could not follow up every 3 months for their diabetes examinations, as had been protocol at my previous clinic. I was introduced to the discount prescription formularies offered through stores like Walmart and Target, and I realized that these would be my new drug references instead of the pocket pharmacopoeia upon which I had become so reliant. I had to transition into practicing medicine more creatively without the benefit of being able to order expensive tests or the latest drugs. Even with a medication assistance program, patients struggled to obtain insulin or often had to choose between getting laboratory tests done and picking up refills. A visit to our clinic often resulted in patients being sent home with a bag of canned goods or other nonperishable groceries to help them avoid having to choose between feeding their family and taking their BP medication.
I came to appreciate these formularies and became more familiar with the myriad of programs available to my patients for free preventive healthcare and locations for discounted laboratory and radiologic tests. My clinical reasoning skills became more astute, and I began relying more on my history and physical examination than on expensive tests. I began shifting my mindset from covering myself in case of a lawsuit to ensuring that I was not ordering more than what was absolutely necessary. I began practicing medicine to the lowest common denominator, and it was liberating to know that I really could rely on these strategies to make the diagnosis in most cases.
Despite this renaissance, frustrations abound. Patients who truly need more expensive testing for potentially serious conditions either find themselves with bills they cannot pay or refuse to go at all, resulting in a conundrum for providers. We are advocates for our patients, yet we are at the mercy of their pocketbooks when they do not qualify for our state and federal Medicaid programs. I am working with several patients who have had some basic tests that point to cancerous tumors, yet who refuse to follow up further because of their fear of the system and the financial liability they may incur. We have discussed that this refusal could lead to their early death if untreated cancer is indeed running rampant in their body, but they remain steadfast. Their fear of medical debt trumps any fear of cancer and dying. Is this truly “informed refusal”?
How my practice will be affected by the Affordable Care Act (ACA) is unclear. For those of us working in underserved areas or with underinsured or uninsured populations, we hope the ACA will expand access to care. We hope we will not have to cross our fingers that a patient will show up for a follow-up visit after going home with a new medication. We hope the ACA will let us order those previously untouchable medications when necessary. We hope that fear of debt will no longer have to take center stage when further testing is required.
Although I am not naïve enough to think that the ACA will fully bridge the gap between my patients' medical needs and their pocketbooks, I do hope I continue to make diagnoses using the fewest tests possible and to treat patients with the most cost-effective medications. These medical arts have been largely lost in a society plagued by litigiousness. I am learning to trust my skills, and being forced into this type of practice has truly been illuminating. Not all abdominal pain needs imaging. Not all cases of fatigue require a battery of blood tests.
Ultimately, I hope that someday those of us working in these underserved areas can provide whatever care is necessary without having to rely solely on our patients' pocketbooks. And if this becomes reality, I hope I do not lose my reliance on the basics of the history and physical examination. That is something we PAs have always excelled at, and we should continue having confidence in those skills.