buckeyes Posted May 7, 2011 Share Posted May 7, 2011 I am close to finishing up rotations and have not had a rotation where I didn't see a patient that needed a test but ran into trouble with financial issues/no-insurance. This last week, patient with known CAD and stents placed 5 years ago came into the clinic with chest pain that he claims is similar to the chest pain he had before the stents were placed. Pain happens with activity and resolves with rest 4-5 minutes later. He hasn't taken any medicine for his HTN and HLP in the last 3 years due to finances and has not seen his cardiologist in 4 years due to lack of insurance. This guy needs to see his cardiologist and have an angiogram, but no insurance is of course a barrier to that. After talking with preceptor, we decided the plan would be to have him attempt for disability to get coverage and then see his cardiologist. Start aspirin, lisinopril for BP, nitro for pain, draw some routine labs with lipid panel, and of course go to ER next time chest pain happens. I feel like this guy's best chance is to have an episode of chest pain, go to ER, get admitted, and get his angiogram. But I hope he is able to get coverage. Would any of you dealt with this patient differently or any other advice for helping a patient in this condition? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted May 7, 2011 Moderator Share Posted May 7, 2011 I feel like this guy's best chance is to have an episode of chest pain, go to ER, get admitted, and get his angiogram. But I hope he is able to get coverage. yup. "go to the er " is a common national health policy in america today as it is frequently the only way to get things done. other options include performing a basic stress treadmill as many cardiologists want to see "objective evidence of new ischemia" before a return trip to the cath lab. also re: meds, many free clinics can provide these. Link to comment Share on other sites More sharing options...
bradtPA Posted May 7, 2011 Share Posted May 7, 2011 I might of started him on ranexa instead of ntg, but that's because I have enough free samples to cover him for at least three months, and sent him to the ED for a full workup to rule out an NSTEMI and where he could have gotten the stress test before discharge. Link to comment Share on other sites More sharing options...
marilynpac Posted May 7, 2011 Share Posted May 7, 2011 Aren't there any free clinics in your area that could deal with this? I know my area is just starting to get them, but other areas are much more advanced... Link to comment Share on other sites More sharing options...
d2305 Posted May 8, 2011 Share Posted May 8, 2011 He can get 3 mts of meds @ wallyword or target for $10. Most had a pack of generic cigarettes in their shirt pocket and claim they're broke. Link to comment Share on other sites More sharing options...
brookspa Posted May 8, 2011 Share Posted May 8, 2011 PLEASE.....stop with the "disability" option. altruism is just fine if you want to pay for it your self, i do not. LSW is ok sociologist is ok, as are other fields. medicine IMHO is for us to do the best we can , for who we can, for as many as we can, with what is at our disposal. However, there is a huge number of people out there who cannot afford meds or dr visits but can easily afford cigs, beer. dope, cars, vacs, and other things they consider necessities but not meds or docs. just sayin... Link to comment Share on other sites More sharing options...
marilynpac Posted May 8, 2011 Share Posted May 8, 2011 You forgot to mention the gambling boat.... Link to comment Share on other sites More sharing options...
Joelseff Posted May 9, 2011 Share Posted May 9, 2011 d2305, BrooksPA and Marilyn: Amen and amen!!! I had pts in my IM rotations that CHOSE to buy a pack of newports in a box and Lotto tix vs lisinopril and ask me for samples.... Link to comment Share on other sites More sharing options...
rcdavis Posted May 9, 2011 Share Posted May 9, 2011 I am close to finishing up rotations and have not had a rotation where I didn't see a patient that needed a test but ran into trouble with financial issues/no-insurance. This last week, patient with known CAD and stents placed 5 years ago came into the clinic with chest pain that he claims is similar to the chest pain he had before the stents were placed. Pain happens with activity and resolves with rest 4-5 minutes later. He hasn't taken any medicine for his HTN and HLP in the last 3 years due to finances and has not seen his cardiologist in 4 years due to lack of insurance. This guy needs to see his cardiologist and have an angiogram, but no insurance is of course a barrier to that. After talking with preceptor, we decided the plan would be to have him attempt for disability to get coverage and then see his cardiologist. Start aspirin, lisinopril for BP, nitro for pain, draw some routine labs with lipid panel, and of course go to ER next time chest pain happens. I feel like this guy's best chance is to have an episode of chest pain, go to ER, get admitted, and get his angiogram. But I hope he is able to get coverage. Would any of you dealt with this patient differently or any other advice for helping a patient in this condition? Let us, for the sake of discussion and to unmuddy the waters, assume that he is one of the working poor, who does not smoke nor pour his paycheck into a bar, brothel, or bingo. That he is trying to pay his mortgage and maybe a Kid's education plus a car payment. And as we know, he has known CAD w/ hpl., is status post (I assume multiple) vessel stentng, and who now could be the patient Heberden first described in his paper to the royal college in 1758 on angina pectoris. He cannot afford specialty and subspecialty follow up.. In fact has not been able to afford a lot of the medications previously prescribed for him. What to do.. Oh what to do? Okay. In a perfect world, stress, stress echo, angio and may be re-stent. But wait... Not all angina requires intervention. And, just as you do with patients with critical stenoses who are not suitable operative risks, there are more ways to skin the cat. First, do as you did.. Get him on as many walmart $4 Meds as you can.. Antihypertensives, antilipidemics, aspirin, and betatron blocker if the original stent was due to an infarction. Add a long acting nitrate for baseline. Weight loss, diet.Glass of red wine a day. Make sure that he understands that angina is represents the natural progression of ASCVD and has degrees. That he has to do his part, which means adherence to the plan and the Meds. See him every other week or every month. The goal now is to try and increase exercise tolerance... I would suggest that You do not need a stress test in this patient.. Assuming he has normal lung fxn his exertional chest pain IS your stress test.. Mandating intensive medical treatment. While you are intervening medically ( not merely "stabilizing, but stabilizing plus risk factor modifying), you hopefully can increase his exercise tolerance to such a degree that he can continue his job. Hopefully he is not a laborer. Only if the exercise intolerance precludes him doing his job should he be considered temporarily eligible for disability... The mere fact that he needs a study, or that we want him to have a study, does not entitle him to disability. And you might be able to ask your local hospital if they can do him as a charity case, or for a reduced fee... ALL non-profit hospitals are REQUIRED to provide a certain percetange of there income for charity care... He may qualify.. Further, PTCA has become the cardiology first step in almost all CAD, not all anti al patents need it.. And many can be treated by simply being treated intensively and well. Hopefully he will be one of the lucky ones that can have their disease managed by medical treatment. We all face this dilemma daily. The nurse says "I know you ordered this test, but he is self pay..." and that fact slams us with the harsh reality that everything has a cost.. And not all tests/procedures are absolutely no-doubt-about-it necessary. I think it is fair to have a frank discussion, a gentle, non judgmental or demeaning discussion, with our patients.. Telling them what we think they have, and what we propose to do about it. Tell them what tests we would like to get, which tests are " nice to have" and which tests are " got to have", and which " got to have " tests we really could live without it we had to... If they are too expensive for the patient.. sometimes sacrificing the test so the patient can afford the treatment is the better course of action. And for those who are worried about the lawyers and the patient 's families in the case of adverse events.. I would suggest that carefully and thoroughly documenting your thoughts, your plans, and the trade-offs hat you and the patient made in face of financial constraints, will pretty much keep you out of sustainable trouble. A lot of what we do really ain't rocket science. A lot of the "art", though, of how we do it, is found in our approach to patients like yours.. Who have real disease and limited resources.. These patients will and do exist throughout your career. They can be frustrating ( like your patient) or tragic ( I had a pretty lady who had half her face blown off by an angry boyfriend's shotgun blast.. So disfigured the only men who would date her were bikers... And she worked.. No insurance.. I tried for three years to find a maxilofacial or p,plastic surgeon to help reconstruct her face... Even national organizations). Sometimes we will win the battle ( finding that not for profit who will help your patient with the finances of the studies), sometimes we will lose ( as I did with my shotgun face lady), but the patients we serve will know, they just will, that you were there for them, that, even in your inability of changing reality, you at least attempted to help them. Anyone, even a dunce like me, can refer unstable angina to the cath lab for intervention. The artist and genius is the doctor who takes care of the same patient when the cath lab for whatever reason is not available. Welcome to medicine. davis Link to comment Share on other sites More sharing options...
Moderator ventana Posted May 9, 2011 Moderator Share Posted May 9, 2011 Very interesting topic early in my career I would bend over backwards for the uninsured. Honestly now not so much. I still help the occasional person by writing off a visit and coding the lowest visit but I am in MASS where most people have insurance (only see about 1 per week that is self pay). Also, have had a change of heart for the whole uninsured person. Sorry to say but most of the uninsured I saw were making the choice to be uninsured (Massachusetts has done a good job with getting insurance to people) so my sympathy/empathy for them is greatly diminished. Also, I realized that the only likely way our broken system is ever going to get fixed is if we stop bandaiding it. I still see patients for free every once in a while, I write almost all my drugs off the $4 list, will work with people on bills, but no longer do I feel it is my problem. I know it sounds harsh, but I have the luxury to live in a state that has done a great job getting people on insurance so is almost a moot point for me. (yet I still make the occasional call to cardio or ortho to say 'please see this person with out insurance" but I understand when they say send em to the ER) so to answer you question: I would refer the guy to cardio and document he declined and that he was choosing to have me mng his angina, then $4 drugs (especially high dose statin, ASA) then Beta(if MI), ACE, Check HgA1C, and BP control. I would no stress him - mini stress with each exercise - or maybe call the old timer cardio local and see if he could do a EET cheap - ONLY if the guy was a nonsmoker and trying to make it on a paycheck would get EKG and old EKG would bill level 2 and 3 visits for him (he will have more visits with me then with a Cardio and I tell them this right up front) get him in touch with local advocates for insurance if at anypoint I got the feeling he is leaching I would have to revisit (i.e. I got this tan when I went on a one week cruise for a vacation) Link to comment Share on other sites More sharing options...
buckeyes Posted May 10, 2011 Author Share Posted May 10, 2011 excellent, thank you davis for helping me step back and take a different angle on the situation Link to comment Share on other sites More sharing options...
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