Caring for Our Uninsured Patients

As fellows, we have all encountered uninsured

patients in either the hospital or the clinic setting.

Depending on the type of practice where you are

training (eg, private vs university, urban vs rural),

there will be a different proportion of patients who

lack insurance coverage. According to the Kaiser Commission

on Medicaid and the Uninsured, in 2009 there were 50 million

people in the United States under the age of 65 who lacked

health insurance. In many parts of the country, the stereotype

of the uninsured homeless patient has been replaced by

uninsured working families, who now make up more than

three-fourths of the uninsured population. The increase in

uninsured patients crosses age and ethnic boundaries and

affects their health because they are unable to receive both

the preventive and therapeutic care they need. In the case of

our patients, the need both emotionally and financially will be

high if they have a new diagnosis of cancer.

Unfortunately, the number of uninsured patients is

increasing at a time when the cost of cancer care continues

to rise. According to the National Cancer Institute, in 2006

cancer care accounted for an estimated $104.1 billion

in medical care expenditures in the United States. As we

develop advanced molecularly targeted therapies, this

number continues to rise. To an individual patient, there

is variability in the cost of cancer therapy, but when you

consider the cost of chemotherapy, surgery, radiation, and

supportive medications, it’s easy to reach tens of thousands

of dollars per treatment regimen. For all but the wealthiest

patients, this becomes cost prohibitive without insurance

coverage or another means of financial support.

As medical students and residents, we often are able to

defer insurance status issues to a team of support staff,

such as social workers and case managers. As we transition

to attending positions, the issues of insurance coverage

become increasingly apparent and important to understand

because of the potential interference in our ability to

provide excellent care. By understanding the unique

challenges of the uninsured and the resources available to

them it is—in most cases—possible to provide them with

the same excellent care as their insured counterparts.

Unique Challenges of the Uninsured

Throughout my fellowship, one of the main observations

was the similar challenges that are faced by patients

with cancer. Patients of every age, socioeconomic status,

religion, gender, and insurance status are subject to

the same disappointments and fears that accompany a

cancer diagnosis. In addition to similar human emotions,

uninsured patients have an additional set of worries that

is unique to this population. An example that has left a

lasting impression on me during training was a middle-aged

patient who was battling advanced pancreatic cancer.

Her poor prognosis and declining health were obvious to

me, the attending physician, the patient, and her family

as she progressed through treatment. As we aggressively

treated her symptoms of pain, nausea, and weight loss, we

found that we could not treat her biggest worry: losing her

insurance if she was forced to stop working. Despite her

symptoms, she continued to work 2 jobs in order to pay for

medications and maintain her insurance for her family as

she reached the end of her life. For uninsured patients, in

addition to the obvious stresses of a cancer diagnosis and

the effects of therapy, they are burdened with bills that may

be difficult or impossible to pay.

Many patients may feel embarrassed or self-conscious

about the fact that they cannot afford their medications.

For example, while rotating through my gastrointestinal

oncology clinic, I had a patient with locally advanced rectal

cancer undergoing neoadjuvant treatment with concurrent

capecitabine and radiation. Despite extensively educating

this patient on the importance of compliance with twicedaily

capecitabine, he consistently missed doses. As I

discussed the case with my attending, I was frustrated

and angry at this patient, as I felt he had a potentially

curable cancer but was compromising his care by not

complying with his medications. My attending was able

to further explore why he was noncompliant, and the true reason was that he was forced to choose between paying

for his medications or food for his family. Because he

was underinsured, he could not afford his medications

and therefore was rationing them by taking them every

other day. He was too embarrassed to admit that he

did not have enough money and was therefore willing

to compromise his care. This situation could have been

avoided with better communication with the patient. As

fellows, we may sometimes feel unequipped to deal with

these treatment-cost issues and may avoid asking our

patients if they need financial help.

Utilizing Resources

As insurance coverage becomes increasingly more complex,

we have all learned that some of our best allies in the

hospital and clinic are our social workers. As fellows, many

times the responsibility falls on us as the junior members

of the team to communicate with the social workers to

ensure that the patient has adequate insurance. There

are services through government agencies, the American

Cancer Society, drug companies, private funds, and other

organizations to help our uninsured patients. Utilizing

these resources can require patience, time, and paperwork,

all of which can be made easier if you have a good social

worker helping you through the process.

Another unique barrier I have encountered in

the uninsured patient is the challenge of adequate

transportation. Cancer care requires frequent physician

visits, which can be as often as every day if a patient

is receiving radiation therapy. It is easy to view missed

appointments and cancellations as irresponsible and

noncompliant, but transportation can be expensive and

the patients may need assistance simply getting to their

appointments. Again, a social worker or case manager

can usually help find a community or hospital resource to

provide this essential service.

Patient Care and Insurance Status

In my experience as a fellow, I have been fortunate enough

to be surrounded by physicians who provide excellent

care regardless of a patient’s ability to pay. I am idealistic

enough to believe that the treatment plan of an uninsured

patient should be of the highest quality and equal to that

of his or her insured counterpart. I am realistic enough,

however, to know that in today’s healthcare environment

there are limitations to what a hospital or clinic can

provide patients who do not have

insurance. In my experience, if a

patient cannot receive treatment

due to inability to pay despite all

the resources available, we refer to

the local county hospital, which is

able to treat the patient at no cost.

While this may feel like you are

abandoning him or her, ultimately

the goal is to provide the therapy our patients need and it

may not be possible depending on where you work.

In the United States, we are fortunate that, in most areas,

offering substandard oncologic care solely due to lack of

insurance is not acceptable. We have clinics and hospitals

that are state and federally funded to help patients who

do not have insurance. Unfortunately, even with these

services, an uninsured patient’s care may be negatively

affected in many ways if they cannot access the care they

need. Even with free care, there can be significant difficulty

in transporting the patient to clinics, which may be a great

distance from his or her home, and treatment delays that

plague many county healthcare systems. If the number of

uninsured patients continues to increase, there is no doubt

that these systems will be flooded and the challenges to

provide adequate healthcare will be magnified.

The Future of Insurance and Oncologic Care

In this depressed economic environment, there is no doubt

that the number of uninsured and underinsured patients

may increase. President Obama has made dramatic changes

to our healthcare system in the Affordable Care Act of 2010,

and the implications of this legislation are still premature.

The hope is that there will be more insurance coverage for

those Americans who really need it to get the care that

they deserve. In addition to providing insurance coverage

to a wider population, it will demand that our healthcare

system become more evidence-based, efficient, and cost-effective.

As this legislation unfolds, there will be a need

to balance the financial sustainability of our healthcare

system with the growing needs of our patients in the clinic.

As oncologists in training, we rigorously study treatment

guidelines and strive to be evidence-based physicians who

offer the highest standard of care. In today’s healthcare

environment, it will be important to also be aware of the

resources available to help navigate the system to actually

deliver this therapy to our patients. When we graduate

fellowship, there will be many opportunities to work in

different environments, from private practice to academic

centers, which may offer a range of resources to help you

provide the care you have trained for. In my opinion, that

is one of the many factors to consider as we take the next

step to becoming an attending physician.

Sheetal M. Kircher, MD, is currently finishing her oncology fellowship at Northwestern University in Chicago, IL.