Hard Questions

Charity case


A 45-year-old comes to the emergency department because of abdominal pain for the last few months. She has been belching and hiccuping, and she has lost 20 pounds.

A 45-year-old comes to the emergency department, where a CT scan shows a large mass in her stomach. There also are enlarged lymph nodes nearby and far away, and the wall of her abdomen is studded with smaller tumors.

A 45-year-old comes to the emergency department and is told she needs to be admitted to the hospital to work this up. It’s likely cancer, she is told, but the only way to confirm the diagnosis is with a biopsy. They do a procedure in which they insert a camera through her mouth and down her esophagus, and they take a sample of the large mass in her stomach. It is cancer – and it’s widely metastatic.

The resident on her team sends me a text. She wants to know: “What do you do in cases like this?”

Except she is not asking for my advice on medical management. The same day the patient is told it’s cancer, she has a confession. She has no insurance.

Dr. Ilana Yurkiewicz is a fellow at Stanford (Calif.) University.

Dr. Ilana Yurkiewicz

I read the text, then turn to the oncology case manager sitting next to me. We talk it through and the answer is as I suspected.

“She can be seen in the county clinic,” I text back, and give the name of an oncologist there. “Or, she can apply for emergency Medi-Cal to follow up at our hospital. But that process can take over a month to get approval.”

Except the case manager looks into it further. Actually, she does not qualify for emergency Medi-Cal because she invoked it earlier that year when she had an infection.

When it’s an emergency, hospitals tend to handle this kind of situation well. I’ve seen hospitals absorb the costs of major medical interventions when a person is acutely ill. They call it a charity case, and they cover all the costs of acute illness and treatment when the patient cannot.

But what this person needs is different. The treatment she needs is not emergent. What she needs is a regular oncologist who can give chemotherapy, monitor for side effects, check her blood counts, get regular scans to monitor the disease, and have conversations with her to navigate the bigger questions. What she needs is an ongoing relationship.

That is harder for a hospital to absorb.

I think back to a year ago, when I was volunteering at the free clinic. A 77-year-old man came in complaining of increased urinary frequency. I did a rectal exam, and I felt it: a large, irregular prostate mass. I thought of all I would normally do, down the algorithm of treatment – I’d order a PSA blood test, arrange for him to have a biopsy, likely get a CT scan, then get him back in the clinic to start treatment. But there, I could not do any of that. There, I was lucky when I could get someone a $4 medication. There, all I could do was hand him the truth. “I am concerned you have prostate cancer,” I said.

I remember how he began crying tears of joy. “God bless you,” he said, grabbing my hand. God bless me? For what? For handing him a problem but no solution? For sharing a suspicion of a diagnosis that could kill him but being unable to intervene? Is it really better knowing?

I deliver a lot of bad news in oncology, but I usually get to blame the disease. The cancer is aggressive. The cancer is causing your pain.

What I hate perhaps even more is the other type of bad news: having our hands tied by a system I disagree with – and yet am somehow part of. We can offer X, but not Y. You can be seen in this clinic, but not in that one. This treatment is covered, but that part would be out of pocket. Negotiating what is absolutely necessary and what is preferred.

A 45-year-old comes to the emergency department with abdominal pain. She is told she has metastatic cancer that will take her life in less than 6 months without treatment. She has many questions for me, the inpatient oncology fellow. But they are not about the disease, the prognosis, or the treatment. They are all about insurance options, reimbursement, and cost.

Like everyone with a new devastating diagnosis, she is weighing her options. Except her decisions are weighted with the fear of bankruptcy; her calculus trying to compute the cost of her life.

“I wish things were different,” I say.

Minor details of this story were altered to protect privacy.

Dr. Yurkiewicz is a fellow in hematology and oncology at Stanford (Calif.) University. Follow her on Twitter @ilanayurkiewicz.

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