"I've been getting winded lately."
He's a middle-aged man with diabetes. This kind of thing is a "red flag" on certain patients. He's one of those patients.
"When does it happen?" I ask.
"Just when I do things. If I rest for a few minutes, I feel better."
Now the red flag is waving vigorously. It sounds like it could be exertional angina. In a diabetic, the symptoms of ischemia (the heart not getting enough blood) are atypical. It's the pattern of symptoms that is the most important, and to have exertional shortness of breath which goes away with rest is a pattern I don't like to hear.
What he needs is a stress test - more specifically in his case, a nuclear stress test (because his baseline EKG is abnormal). But there's a problem: he has no insurance. A nuclear stress test will cost thousands of dollars.
I can refer him to the hospital, but I know the financial situation he and his wife face. They have no money because of a chronic pain problem he has. He hasn't worked in several years, but hasn't ever been able to get disability either ("I tried, but was denied three times"). Without insurance he's not able to get his problem fixed, so he's disabled. But he can't get disability, so he can't get insurance to get his problem fixed and no longer be disabled.
But the problem on hand is this: he needs a test he can't afford.
There are many folks out there in this same situation. It may not just be the people with no insurance, and it may not even be people who don't have money. In fact, my own family is facing this same problem. Multiple family members (myself included) need dental work done. Some need it done badly, yet we don't yet have the money to pay for it. So we wait for the money to show up while the problems gets worse.
Many problems are being put off because of high-deductibles or under-insurance. Sure, the ACA has helped people get insurance, but many people got the "bronze plan" and so pay out of pocket for much of their care. What ends up happening is that folks don't get their blood pressure managed, their diabetes controlled, or their shortness of breath assessed because it simply costs too much to do so.
And so my patient, who has a lot more than cavities, puts me in a difficult situation. He can't afford to wait to get this test done, but he can't afford to get the test done. We will do what we can to find ways to find the cheapest way to assess this problem and potentially fix it, but I am not sure exactly how we will accomplish that.
Until our system can figure out a way to handle this kind of thing, we will pay a big price. Waiting for problems to become emergencies is a terribly expensive practice. I'm not sure I know exactly what needs to be done for this, but it's becoming an increasingly common problem. Some say that a single-payor system will be the remedy, but they ignore the fact that a third-party payor system is what got us in this mess in the first place. Things are far too expensive because patients don't have to pay for them. That's why stress tests, which don't actually cost thousands of dollars to do, are so expensive. That's why there is $100 hemorrhoid cream. That's why medications are unreasonably expensive: someone else pays the bill.
I hope the answers are out there somewhere. I'm trying to work on ways to negotiate cheaper prices for my patients for such services, but this kind of thing will take a lot of work and will have to overcome a lot of inertia. It's going to take time.
Unfortunately, my patient with shortness of breath may not have so much time.