What's my Worry Today in Primary Care?

Worrying about patients is part of my job. In these last couple of weeks it's been a long-time patient with a life-threatening illness, a pregnant woman who didn't want to be pregnant, and a young person who thinks that a pill will fix her out-of-control life. (I get a lot of older folks who are looking for that magic pill as well but they don't worry me as much). Mostly I leave those thoughts at the office but sometimes they come  home with me. Lately what's followed me home are patients who are avoiding treatment or visits because they have a high deductible or no insurance at all. Last week was a middle-aged woman who just got insurance after being without for several years. She had several concerning issues but the most worrisome to me was the thickened area in her breast. She didn't tell me about it but on physical exam there it was--it felt wrong. It didn't belong there. It was a little hard, a little irregular. Classic sensation for a cancer.. She hadn't had a mammogram or a physical in years because of the cost. Would it have made a difference if she'd had one last year? I don't know. Maybe. And maybe this "area" will prove to be nothing, though I doubt it. 

The number of uninsured Americans has gone up a few percentage points in the last ten years. What I am seeing more of are underinsured individuals--people with high deductibles and high premiums. These are the people who skip needed care because they can't afford it OR they have the perception that they cannot afford it. They are "non-adherent" with medications because they fear the cost of followup lab tests even when their medicines are on the $4 Kroger list. They don't come see me because they don't know we offer a 35% price cut for cash paying patients. They equate health care with health insurance. They are aware of the skyrocketing costs of hospitals, medicines and doctors and fear that if anything is found on exam that they'll never get insurance (a reasonable fear to have these days since many people are outright rejected and others are quoted outrageous premiums based on what are often minor problems). Or the patient may obtain insurance without coverage for a pre-existing condition.

I await the mammogram report with trepidation and hope she doesn't skip it. She was concerned about missing a couple of hours at her new job. God forbid she lose the job that is supplying her with health insurance. I am sure she can't afford COBRA. And if the worst occurs will she lose her job anyway because she can no longer work while going through surgery, chemotherapy and radiation? And then what?