No Insurance, What To Do?

Written by: Everett Castle, MD, FACEP

Many people locally and nationally are without health care coverage due to many causes. Some include unemployment, not eligible for Medicaid or Medicare due to income or age requirements, taken off AHCCCS rolls, dropped from insurance plans due to unemployment, or inability to obtain insurance for preexisting conditions. Majority of Americans are covered by health insurance third party private or government entitlement programs Medicare Medicaid and/or government employee (military or public employee). There is a significant portion of population (25 million) who do not have insurance of any type.

How to obtain care and navigate the existing health care system can be problematic and expensive for most. When I first stated practicing medicine in mid 1970s most office practices allocated 10-15% of care for indigent patients. With the development of government programs and EMTALA (Emergency Medical Treatment and Labor ACT) law many physicians stopped this practice and referred patients to emergency departments across the country. Private practices seldom care for the uninsured due high overhead costs which include malpractice costs, office employees and small business costs (rent utilities). The EMTALA law passed by congress in 1986 provided a national safety net for health care. Due to the EMTALA law passed by Congress all patients must be evaluated by a provider in emergency departments across the country regardless of ability to pay, nationality or availability of insurance coverage.

Emergency Physicians provide the most charity care of all Physicians in the United States (AMA 2003). ACEP (American College of Emergency Physicians) advocates the care given to indigents as a legitimate practice expense. Some specialists in high risk specialties of medicine see this as a reason not take call for the emergency department. A few emergency physicians see this as being an indentured servant. Many laws passed have unintended consequences. The number of emergency departments has declined from 2,446 to 1,779 from 1990 to 2009. The most notable is St Vincent (catholic hospital in Manhattan, New York). This facility gave extensive indigent uncompensated care and closed in April 2011 due to debt of 700 million dollars. Today the building is being demolished and luxury condos will replace the 160 year old, 758 bed teaching hospital, and level one trauma center.

Thus emergency departments across the nation and locally are overcrowded, have long wait times, and poor availability of specialist call. These trends will continue until Congress passes universal health care coverage for all Americans. Physicians are turning away AHCCCS patients due to low reimbursement rates. Indications are if Medicare rates are lowered in the future, patients will have limited access to primary care by health care providers. There is a shortage of primary care physicians across the country especially in the rural areas. A positive trend is the development of the use of Nurse Practitioners and Physician Assistants in primary care in rural and urban areas.

In Cochise County the Doctor of Osteopathic Medicine (D.O.) residency program at Sierra Vista Regional Medical Center is producing residents who are heavily in to debt with undergraduate and medical school loans $300,000-$500,000. Some good news is that the government offers graduating doctors some loan forgiveness up to $60,000 per year to work in under-served rural health environments such as Cochise County. Some of these graduating medicine and primary care doctors should opt to stay in Sierra Vista and alleviate the lack of primary care availability.

As of 2011 there were 40 million recipients enrolled in Medicare. In 2011 the first of 77 million baby boomers entered the Medicare rolls. Estimated 10,000 people will turn 65 years old daily and will be eligible for Medicare coverage. This puts additional strain on availability of medical care. Obama care will add an additional 30 million people to the new insured list. There still will be an additional 25 million people who are uninsured. These excessive numbers of people indicate future difficulty in finding a primary care provider and even longer Emergency Department waiting times. Urgent care centers across the country will take up some of the slack.

The physicians and health care providers at the High Desert understood the demographics and the future health care needs of the community. Presently we are increasing Saturday hours to meet the demand. Expanding to more hours open will be an option for the future if is needed.

If you need immediate care for an emergency i.e. heart attack symptoms (chest pain, diaphoresis (excessive sweating), SOB (shortness of breath); stroke like symptoms; severe headache; major fracture; seizure; MVA (motor vehicle accident); and/or psychiatric issues, the emergency department is the place to go regardless of ability to pay. The Emergency Department per EMTALA law will evaluate you and provide care. For others with minor emergencies and in need of immediate care or evaluation the Urgent Care or your health care provider’s office is more appropriate.

At the Urgent Care we provide a 25% discount for cash pay patients. Urgent Care unlike the emergency department, are not obligated to see patients for free. The Urgent Care is provides timely care and if you are found to be too ill to managed in the clinic a referral to the hospital will be arranged for further evaluation and care. The Emergency room and Urgent Care are not the ideal settings to control chronic medical conditions like diabetes, hypertension, asthma, and chronic obstructive pulmonary disease (COPD).

For patients with no insurance, no health care provider, underinsured, and in need of prolonged care, the Chiricahua Community Health Centers clinics are ideal. They have three locations – Douglas, Bisbee and Elfrida. They also have a mobile clinic which goes to Huachuca City and Sierra Vista (520-459-3011). The charges are on fee for service sliding scale based on ability to pay. A dental mobile clinic is also available (520-642-2222). Women’s Health services and STD checks and treatment are also provided at these clinics.

Obtaining dental care can be problematic will minimal financial resources. Dental care is usually cash pay. The dentists in the USA never took state or federal money to provide for indigent care and remain in the cash pay business model. Some dental practices will allow patients to pay over time to lessen the financial burden. Dental insurances are available which cover some of the cost. In this country many people cannot afford any dental care and result in frequent emergency departments visits across the country. One hundred and twenty-million people in USA do not have dental insurance. In 2009 – 890,000 Emergency Department visits were for dental problems costing 10 times what a dental office would charge. Locally there is the mobile Chiricahaua dental clinic which is on sliding scale fee for service and fixed dental clinics in Elfida and Douglas that are also run by Chiricahua Community Health Centers. Across the border well trained Mexican dentists can provide dental care at about one- third the cost of dentists locally. Tucson has the St Elizabeth of Hungry dental clinic but there is a long back log of patients and you may not be seen for many weeks.

Obama care makes reference to midlevel providers, such as trained dental hygienists and therapists to offer basic cavity treatment. Currently only Alaska and Minnesota currently allow midlevel dental care providers.

Some prescription medications can be costly. Several pharmacies have a $4 prescription list (Target and Walmart) Ask the pharmacists at these pharmacies for their list. For more expensive drugs I use out of country pharmacies. I obtain some of my medications from the Discount Drugs from Canada (Toll Free 1-888-888-9950) (FAX 1-888-862-1600). The process is to obtain a prescription from a provider and fax the prescription to the above FAX number with your health care provider’s name and your address. After your initial purchase sending a check the pharmacy will send your medications to your address. After your first purchase you send your check for the medications after they arrive. Plavix costs $275 for one month supply in USA and through this Canadian pharmacy 90 days supply is $275. A great savings can be obtained using this service. Many of medications on the $4 list are obtained from the same sources that this Discount Drugs from Canada use.

This is the first monthly article which will be on our new web site for High Desert Clinic in Sierra Vista. We will cover local, state, national and world health care issues in our health care blog. Future articles will include local health care news, Obama care updates, hepatitis C, STDs, bath salts abuse, drugs of abuse, prescription drug abuse, Alzheimer, elder care, end life of issues, and hospital medication shortages.

The future is not predictable, but if on going trends continue, obtaining health care will be problematic.  With limited financial resources at the local, state, federal government levels and with diminished reimbursement, more hospitals will close and more physicians will exit Medicine or limit Medicaid and Medicare patients. Health care providers have a difficult time following and implementing the 130,000 pages of Medicare rules and regulations and impending change in billing codes (140,000 new diagnostic codes). Fines for billing errors and fraud have increased form $10,000 to $50,000.

Congress needs to drift away from partisan politics and embrace bipartisan cooperation and address the problems of the uninsured, those with preexisting conditions who are unable to obtain health insurance, immigrant health care, and reform the entitlement programs. Obama care may address some of these issues, but the Supreme Court has not at the time of writing this blog passed ruling whether the law will remain intact. Solutions can occur with innovative taxation, diminished rules and regulation, and seeking of free market solutions. We all need this to occur – it is our lives, our family lives, our neighbor’s lives, and our future children’s lives that will benefit.

Written by Everett Castle, MD, FACEP

Everett Castle, MD, FACEP is the current Medical Director and Corporate Manager of High Desert Clinic Urgent and Occupational Care in Sierra Vista, Arizona. Born in Tucson and long-time Arizona resident, Dr. Castle attended the University of Arizona as an undergraduate. He graduated from the University Arizona College of Medicine and completed his postgraduate medical training at Maricopa County Hospital in Phoenix.

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