By Neel Butala, MD
There he sat, hunched over with rugged, muscular arms stretched across his abdomen, his weary eyes stealing hopeful glances from behind an otherwise steely facade. Mr. J was a 53-year old Latino agricultural laborer with a history of H. Pylori who presented at our student-run free clinic with persistent abdominal pain, unchanged from his multiple previous visits. As I learned more about Mr. J and his story, I realized that treating him effectively would require understanding not only his medical complaints, but also his broader socioeconomic context. Working at a student-run free clinic serving a largely uninsured immigrant community has complemented my traditional medical education with important lessons about the costs of care in treating patients.
At a previous visit, Mr. J was deemed to fail his medication regimen for eradication of H. Pylori, and our clinic’s referrals department was in the process of scheduling him for an endoscopy for further evaluation. As a safety net provider, our student-run free clinic has established a small network of community specialists who graciously see our patients without a fee. A referrals volunteer had been ferociously advocating the use of one of our very limited endoscopy spots for Mr. J, given the severity of his symptoms and the impact on his livelihood as a day laborer. I learned that our supervising medical directors carefully triage such cases to specialists given that our patient demand far outstrips our limited specialist supply. I was initially shocked to see how such specialist care is rationed quite literally across the railroad tracks from our super-specialist quaternary academic medical center, but realized that relying on physician goodwill alone to assuage the high costs of care for vulnerable populations was not a sustainable solution in the long run. I had witnessed the raw underbelly of a bloated system that does not systematically ration care among those with insurance, but rather haphazardly rations care away from those most vulnerable in our society.
In trying to understand the source of Mr. J’s pain and his need for endoscopy, I probed further about his medications. We had prescribed him a complex 5-drug regimen instead of a simpler 4-drug regimen to reduce his out-of-pocket costs. He eventually revealed that he had not filled one of his prescriptions, omeprazole, because it was too expensive for him. Mr. J had not failed his treatment, but rather could not even obtain it due to costs. Furthermore, he incurred greater indirect costs in missed work and transport for additional clinic visits to resolve his mysterious persistent pain. Providers’ fundamental misunderstanding of the magnitude of the costs of care for Mr. J was leading him down a path of continued pain, extra clinic visits, and unnecessary referrals. I realized that not being aware of the costs of care can lead to waste that reverberates system-wide, especially for vulnerable populations where the relative magnitude of financial cost is high and underlying psychosocial issues can exacerbate adherence to and effectiveness of treatment.
Ultimately, we were able to use clinic funds to provide Mr. J with free omeprazole to eliminate his H. Pylori infection without the need for an endoscopy and he was pain free at a follow-up visit. While I have debated the tradeoffs between autonomy, beneficence, non-maleficence, and justice with classmates in our ivory tower medical school, Mr. J put a human face on the tremendous cost problems we face as a healthcare system. I will always remember Mr. J’s story when I practice as a physician and work to reduce costs more broadly in a nuanced and effective manner in the future. Inspired by Mr. J.’s case, we led an initiative to provide free omeprazole to all patients with H. Pylori at our student-run free clinic. This small up-front investment would not only lead to reduced costs and lower barriers to treatment for our patients, but would also reduce unnecessary referrals, which would free up resources more broadly for our clinic. Similarly, I now believe a small investment in gaining real exposure to costs of care early in medical training can pay off in tremendous returns system-wide in the future.
Neel Butala is a Resident Physician at Massachusetts General Hospital. He was also a contestant in the 2013 Costs of Care Essay Contest.