Entiltement

I was called to see a patient who was being discharged from the hospital. This particular patient was brought as a trauma, received an extensive workup including CT scans, plain films, and MRIs. They were admitted to the SICU and ended up requiring surgery. The patient had therapies and was treated to all of the "amenities" our hospital has to offer. The discharge planner asked me to come in the room to talk to the patient and family, because they were upset about one of the prescriptions.

This, in itself, is not an uncommon occurrence. On occasion, I will make a mistake with a prescription, or forget to include a home medication that the patient asked to have refilled. In this instance, however, the patient and family wanted to talk to me because the hospital's prescription assistance program would only agree to fill part of one of the narcotic scripts that I had written.

This complaint, alone, isn't really that big of a deal. I have a lot of conversations with patients about their ability to pay for medications. When I write a prescription for anti-nausea medication, I write for both Zofran and Phenergan because although I prefer to give my patients Zofran, it is expensive and some insurance programs will not pay for it. If I know that the patient is self-pay, I explain the difference in cost, give them both prescriptions and let them decide which they can afford. Oxycontin, as another example, is quite expensive. It can be up to $5 per pill.

The discharge planner explained to me that the hospital had limits on what it would provide for different medications, based on cost. Not only that, the discharge planner explained that although the patient had a job (but no insurance), she didn't feel like she would be able to pay for her stay. Because of this, the hospital had agreed to pay for her stay and all of the care that she had received. When you add it all up, the bill is probably way more than $100,000. When the discharge planner asked the patient how much of their care they would be able to pay for, the answer was NONE! The patient and their family expected that all of the care would be provided by the hospital, and had no intention of paying anything.

When I went to talk to the family about the limitations of the program, they couldn't understand the hospital's position. I was left with explaining that all I could do was write two prescriptions, one for the hospital's program, and the other for the patient to fill at a retail pharmacy, which they would have to pay for. They were still somewhat upset when I left the room.

This is not an isolated incident. I have heard many comments from patients stating that they didn't intend to pay for their care. When cost is brought into a conversation about prescriptions or length of hospital stay, patients will often mention that they have a medicare card or no insurance and they will not be paying their bill.

Imagine, for a second, if I went to the nicest steak house in town to order the most expensive cut of meat and the oldest bottle of wine on the menu. Let's say I asked the waiter the cost of these items, and then after his response, commented that it didn't matter because I didn't intend to pay anyway. Do you think I would get served that steak and wine? I doubt it. In fact, I would probably be asked to leave, or even more unthinkable, to pay for my meal ahead of time. If I told that story to 100 people, not one person would find that response by the restaurant to be unreasonable. If, instead, I substituted the story above about the Oxycontin, I don't think the response would be so predictable.

What do we have to do to get across to our patients that they have a responsibility to participate in (pay for) their care? This includes paying for the services of the hospital and its staff. Is the cost of care in our country over inflated? I believe that it is. Should we charge our patients $20 for a Tylenol? Absolutely not! The answer to this problem, is not providing universal coverage to all at the cost of $0. If we expect to reform healthcare and provide coverage to everyone at a reasonable cost, I believe that we have to start from scratch.