April 9, 2008
Can I get my marrow in gunmetal silver?
That's a lot of money. That will buy you a lot of cool things. For example:
A Rolls Royce Phantom
A Nice House
And most importantly, it will buy you this:
A Bone Marrow Transplant.
$350,000. That's a mortgage to some people, but its also the mortgage on your life for people with leukemia and hematological diseases. Most insurance companies will cover some of it. Only the really good insurances cover all of it. And patients have worked out some really creative ways to raise the difference. Bake sales, fund raisers, church gatherings, newspaper ads, dances, concerts, you name it, it's been used to try to gain a cancer patient a second lease on life.
My preceptor's least favorite clinical encounter is when a patient comes in expecting to talk about their transplant, and instead has to talk dollars. Such is the reality in medicine where monetary value is assigned to human life. I was blissfully naive on the state of the health care system coming into medical school. During one of my admissions interviews, a physician asked me what I thought was the #1 problem with health care today. I replied, essentially, "Drug companies. Hiking those prices. Gotta cut 'em down."
*smacks forehead* It's a wonder I got accepted there.
But the more I learn, the more I learn there aren't easy answers. The system is broken and propagated by all members of it. Drug companies propagate it through advertising propaganda and skyrocketing drug prices, which are necessitated by the financial reality that they are just a few failed drug away from bankruptcy. Insurance companies propagate it by cutting corners (aka peoples' lives) to compensate for a drying up subscriber base as more people choose to hedge their bets and go insurance-less than pay unreasonable premiums (though I definitely have less sympathy for insurance companies). Patients propagate the system by expecting a level of care beyond which our economic model can support, refusing to budge in the voters booth when it comes to lowering their standards in order to raise the standards of the uninsured. And yes, physicians are culprits, having to walk the tightrope act between all parties, often having to compromise small aspects of their own personal beliefs in the name of the evil reality called "doctors don't make as much anymore, you got a family, and you're in a crapload of debt."
Last monday, we had to talk $350,000. A woman came into clinic with her 1 year old child - diagnosed with Hurler's Syndrome, a rapidly progressing genetic disorder which, if left untreated, kills its victims by the age of 5. A successful marrow transplant means a cure - even more so than kids with cancer can look forward to. The mom is in clinic and ready to talk transplant. Only problem is, the insurance doesn't add up. The policy is bizarre. It will pay for transport of the donor marrow to the hospital of transplant. But it won't pay for the HLA typing and searching required to find a donor. It will cover part of the cost of the stay during chemo and transplant, but not all of it. All in all, the mother's policy falls about $30,000 short of the full cost of transplant, and thats if the transplant goes without any complications - opportunistic infections, prolonged acute GVHD, and such. If such things happen the hospital bill can reach 7 figures, all on the mother's tab. The mother is not poor, so she fails to qualify for state aid. She is not rich, so $30,000 would essentially financially cripple her. My preceptor can do certain things behind the scenes to cut cost - ordering diagnostic tests from the endocrinologist so it doesn't count toward the transplant cost, using cord blood instead of a full marrow donor, etc, but we're talking fractions of total cost.
I found this case essentially profound for several reasons. (1) Hurler's syndrome is a ticking time bomb with rapid progression. In the time it takes to raise the difference, the poor child's bone, liver, and brain are slowly deteriorating, to the point where he may not tolerate the necessary chemo to produce ablation of the marrow, he may develop lifelong cognitive and orthopaedic disability (2) The transplant is a cut and dried cure. There is no risk of relapse, and we've gotten very good at managing transplant complications. (3) This is a 1 year old child. A child with a chance at a normal life, or just as easily a life riddled with hardship.
Like I said, there are no easy answers. And navigating the financial landscape of medicine is one of those areas we are simply expected to learn and find our way in. We can read articles and spout statistics, but ultimately it comes down to the human relationships we build with our patients and our oath to treat these patients to the best of our ability. It's hard to treat when your hands are in handcuffs. Every physician wishes they had an easy button to push to deal with these difficult situations, a money tree to go harvest to make everything better. But unfortunately the botanists are still working on that one.
Sorry for all the depressing posts lately. I guess thats a byproduct of rotating through a difficult specialty. But its the difficult cases that ultimately hold the truest lessons. I promise a couple more humorous posts soon. We start our last integrated class tomorrow, which will take me through mid-June and freedom. The light at the end of the tunnel is finally in sight.