11 Apr When Was the Last Time You Tried Heroin?
When was the last time you used heroin? In the past have you injected heroin or any other drugs? Are you currently using drugs besides opiates like methamphetamines, cocaine, benzodiazepines or alcohol? After two years of family medicine residency I ask these questions like they are questions that everyone asks in a casual conversation with a patient. Although these types of interviews are customary for me, I recognize that it takes a great deal of courage for a women who is pregnant to speak openly about her opiate dependence with a doctor whom she neither knows nor trusts. For this women, I can sense the internal struggle she faces as she searches for words to explain her current situation. Like many of my patients her struggle has involved constant rejection, a lack of finances, and in general a lack of healthcare. For three years she has been trying to get opiate replacement therapy, and for three years her life has slipped into worsening chaos and instability. After hearing her story I reassure her that we will take care of her, and I ask her how she is feeling about her pregnancy. She pauses and tentatively explains that she initially did not want to continue with her pregnancy, but now she has changed her mind. She continues by explaining that no one has helped her until becoming pregnant, and now she does not want to lose the much needed medical care she can get during pregnancy. For this patient, pregnancy is the cost of getting medical care, and this is a price she is willing to pay.
On the surface, it may seem like the dilemma is whether or not to continue with the pregnancy. As a healthcare provider, I argue the real problem took place long before she became pregnant. The problem starts by not providing early and cost effective interventions that will treat her disease and prevent future expensive adverse outcomes. For individuals like my patient, the cost of getting care and paying for such care is greater than their perceived risk of not getting care. This idea is supported by a recent report from the Kaiser Family Foundation showing only 50% of households can meet the cost of their high deductible, and only 37% can pay their higher out of pocket limit with private insurance. Like my patient, these individuals wait until they are old enough, poor enough, or sick enough to be caught in the torn and threadbare nets of a broken system that seems to only catch patients when they are most sick. This model of health care is not only unjust, but counterintuitive to the public health upstream approach of preventive medicine that averts costly and often times irreversible disease.
When we think about the cost of healthcare we often think about unnecessary interventions, costly labs, imaging studies and inflated charges that are passed on to the consumer. I argue we also increase costs by simply doing nothing, and allowing otherwise healthy individuals to fall into a state of poor health that then requires hospitalization, expensive tests, multiple specialists and long term disability. For this women, pregnancy allows her to qualify for affordable insurance, a program to help mothers with opiate dependence and medical treatment with buprenorphine. In my mind, early recognition and treatment would have stabilized her life, and routine primary care and family planning could have prevented her undesired pregnancy. This type of delayed care will now result in expensive high risk prenatal care and a prolonged hospitalization for her child.
For now she can sleep easy knowing she will get the help she needs, but her pregnancy will not last forever and in the future she may find herself in the same situation. The plague of expensive healthcare is not only a reflection of recurrent acts of commission, but equally the result of procrastinated acts of omission that result in delayed care and missed opportunities to help our patients in a cost effective way. When I think of the cost of care, I think of this women and the price she has paid for the healthcare she deserves.
_______________________________________________________________________________________Joseph Bergsten, MD is a third year resident at the University of New Mexico School of Medicine and was a contestant in the 2015 Costs of Care Essay Contest.