Having just come from surgery, I was used to seeing patients who were in private surgical ICU suites hooked up to expensive vents, undergoing multiple surgical procedures where materials were opened, never used, yet still charged to the patient's bill. Money was never an issue brought up in conversation; it was an afterthought that became reality when the big white envelope from the hospital appeared in the mailbox. Even when I was on my primary care rotation, all but once did a patient have a problem with paying for their well-visit. The PA knew what insurances were accepted by specialty doctors, radiology centers, and pharmacies so that patients had to pay as little as possible. No one seemed to complain about their co-pay and when they went for services such as chest x-rays and laboratory work the patient only opened their wallet to show identification, never to hand over money.
In Belize, the cost of medicine is a conversation we have with almost all of our patients. Roughly 90% of the patients at the clinic are enrolled in the National Healthcare Insurance (NHI). As a member of this insurance plan, only certain medical visits and procedures are covered. By covered, I do not mean the full price of the exam is paid for. Patients are required to pay 10% of the total cost of the exam. For example, the cost of an abdominal ultrasound is $130, meaning the patient must pay $13 for this exam. Everything a patient has to do has a dollar sign attached to it:
- Well-visit: $5
- Blood work: $4
- PAP Smear: $2
- Chest X-ray (a requirement for all hypertensive patients): $4.80
- Abdominal Ultrasound (ex. if someone has belly pain): $13
- Visit to a specialist (internal medicine, cardiology, neurology): $50
When the doctor suggests an ultrasound, or even some blood work, the next sentence out of the patient's mouth is often, "how much does that cost?" The doctor was explaining to us that $50 to a citizen of Belize is a lot of money. Many of them cannot afford to pay those prices for just a consultation.
Today I had a patient who is well known to the clinic for his COPD and chronic cough. It has been quite some time since his last visit, 4-5 months. The doctors, like any other practitioner, had assumed he was doing well. On today's visit, the patient looked sick. I have learned to ask myself when I see a patient for the first time, "Is this patient just not feeling well, or is patient actually sick?" The man was wearing a face mask to shield those around him from his hacking cough, his eyes were ringed with dark circles and his clothes hung loosely off of this body. He was more than a patient with a viral cold, this man was actually sick. He complained of the same cough he has had for years, but he added on a new symptom: weight loss. Past smoker, chronic cough, and weigh loss usually means one diagnosis. We sent him immediately for a chest x-ray. While a CT scan would have been preferred, this radiologic test is not covered in NHI insurance, forcing the patient to pay roughly $400 out of pocket. If you suggested a patient get a MRI, they would be paying a couple of thousand dollars out of pocket. The chest x-ray would have to be enough for this man.
He came back later in the day with a copy of his radiograph. The radiologist read a "tumor-like, fibrotic mass in the left hilar-thoracic region." Even without an official report, the picture said enough. The clinic I am at is a primary care office. We deal with diabetics, hypertensive patients, patients with colds, and screening procedures (i.e. PAP smears, EKG, or blood samples). We are not a place that specializes in cancer. We told the patient he has a mass in his lung and the clinic would not be able to best serve his condition, he needed to see an internal medicine specialist. Immediately he objected. He went into a tailspin about how he cannot afford to spend $50 to only see someone and then be told he needs to pay hundreds of dollars more for a CT scan and even more money for diagnostic tests. The man was more concerned about the cost of his diagnosis than the actual severity of the disease. As he left, we handed him a referral for the specialist but knew that he would never make it. This man would die from his cancer before ever paying $50.
This is not the first time I have faced this type of situation in the previous weeks. A few women have come in with breast pain and on exam I feel something that seems off. It is not a discrete mass, but one breasts feels different from the other. Only women over the age of 40 can get a yearly mammogram as a screening test. If the clinician feels something is wrong and suggests a breast ultrasound, the woman has to pay for the entire test out of pocket. These women do not have the money to spare to get an exam that will most likely be negative. They instead take a prescription for diclofenac, a type of NSAID, with the hope that this pain will go away in due time.
It's not only the patients concerned with money, the doctors are affected as well. The doctors that work for the NHI get paid a set salary. Regardless if they see 10 patients or 12,000 patients a month, they get the same amount of money. Busy days where there are patients after patients for 8 hours straight make it tough to give each person the same level of care. Paid much less in Belize than the United States or other countries, I have never seen a patient who has received a poor level of care at this clinic.
Healthcare in Belize may cost significantly less than in the United States, yet patients in both countries are still receiving the same quality of care. I, unfortunately, have seen too many patients that still cannot afford the least expensive of healthcare options. It often leaves me upset and I worry for the patient's health. Despite all the information and education we provided, they still won't go see a specialist to care for their cancer; the cost of medicine is just too much.
No comments:
Post a Comment