Giving Primary Care to the Uninsured Patient

The Affordable Care Act was supposed to eliminate the problem of uninsured patients by making affordable insurance available to all Americans.  While the law made an early impact, the cost of even the least comprehensive plans eventually rose out of the affordable range for many people.  The repeal of the ACA individual mandate will likely cause a surge in the number of people not carrying individual policies.  While the biggest impact of this will be in the hospital and specialty areas (where cost is highest), the effect on primary-care practices will be significant.

Working in a direct primary care practice (that does not accept insurance for payment), I have a higher proportion of uninsured patients and  have had to develop strategies of getting care for these patients.  This article will address this issue mainly from a primary -care perspective.

The uninsured patient is at constant risk of developing conditions that could quickly bankrupt them.  This makes the job of the PCP, who has to manage the care in such a way to minimize need for specialists and hospital care, critical to both the health and financial well-being of the patient.  Attention to this real and significant stress will not only help the patient, but will also reassure them that the care they are getting is comprehensive.

Here are some guidelines on handling the uninsured patient in the primary-care setting.

Cost Will Drive Care

People can’t pay for what they can’t afford.  This seems obvious, but in health care this causes significant stress.  The diabetic who has no medication coverage will usually choose high sugar food over paying $300 per month on a medication that doesn’t change how they feel.  Don’t get frustrated at this fact, it’s just life priorities.  Yes, there are some who would take high sugars over a $20 per month cost, but don’t confuse the two. It is our job as clinicians to offer care that can actually be received by the patient.  Ignoring cost is no different than ignoring a medication's side effects.

This also means that the clinician must understand the difference between recommended and necessary.  Getting a chest x-ray for possible pneumonia may be recommended, but often it’s only necessary to treat with antibiotics.  A person with a possible foot or hand fracture doesn’t always need to go to the ER or even the specialist.  Many fractures can be managed without problem in the primary-care setting and be done at a fraction of the cost. Simply by focusing on those necessary tests and procedures can save significant money.

Know Where to Get the Lowest Prices

Medicine is notorious for having opaque pricing, and this often drives people to accessible but often dangerous alternatives to the care we can give.  This may need to be the case with insured patients, as the “cost” of any procedure or medication will depend on negotiated prices and formularies.  But the uninsured (or underinsured) patient does have the advantage of being able to talk price up front. 

For medications, there are several websites that can be used to compare and reduce prices of medications.  GoodRx, the most well-known of these sites (which also has a smartphone app), allows users to put in a drug name and compare prices at local pharmacies.  The prices given are actually discounted prices, negotiated and agreed upon by both the pharmacy and GoodRx.  We check GoodRx whenever prescribing anything for an uninsured patient, either to find them the cheapest pharmacy or to see if the medication can be afforded at all.  It’s often very eye-opening to see just how expensive even generic medications can be.  There are other websites/apps that do the same, such as Blink Health or LowestMed.  Encourage your patients to download one or all of these apps to keep prices low.

Prices are seldom affordable for brand-name medications, but pharmaceutical companies have fairly liberal policies for giving medications away for people with low to moderate income.  My staff uses Needymeds to search across multiple drug companies’ programs for free drugs.  Once the staff becomes familiar with the requirements and the mechanics of filling out the forms, the process can be quite fast and people can get the medications needed to manage their diseases. 

Shopping for prices is not limited to medications.  We have found low prices for radiology tests ($250 CT scans, $550 MRI scans), cardiac testing ($100 stress tests, $150 echocardiograms), and recently found a gynecologist that did colposcopies for $150 cash (plus $88 for biopsy).  All we did for this was to call around and ask the various facilities for their cash prices.  Yes, it’s really that easy.

Be Firm When You Have To

There are obviously times when cost has to be ignored.  A person with appendicitis or sepsis doesn’t have the option to shop for care.  They simply have to get care now and worry about cost later.  Fortunately, most hospitals will negotiate down prices substantially after the patient is discharged.  Plus, there is grant money available to most hospitals for the care of the indigent and uninsured patients.  The social workers in these facilities will do whatever is necessary to get the patient some sort of funding for their care.  The financial reward for doing so is huge.

The care of the uninsured patient is certainly more challenging in many ways.  It causes great frustration when a person needs care they simply cannot afford.  But there are ways to address that cost and doing so can definitely be seen as part of the process of giving care.  People are more than just physical bodies, and should be considered on all levels, including economic.  Caring for people’s financial health may lead to better overall health, as they get care they can afford and are willing to follow through.  Doing so will not only make things better for the patients, but it will win their gratitude and trust, both of which are key to a healthy therapeutic partnership.

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