Thursday, March 24, 2005

How we contribute to our patient's bankruptcy

I know that the medical bills/bankruptcy issue has been discussed frequently and recently in the MedBlog world but I want to offer a little different take.

It makes sense that someone who becomes significantly ill will incur a large amount of expense, even if they have medical insurance. According to this study, the journal Health Affairs says that most (75.7%) of the people who declared bankruptcy after a medical illness had health insurance at the onset of their illness. But one-third of those had lost their insurance by the time they filed for bankruptcy.

Why did they lose their insurance?

As one who reviews disability applications, I frequently see doctors decide that their patients can't work. The doctors may or may not list specific restrictions and limitations (see my previous posts on this subject here, here and here) but will often add "can't work" or will indicate that they have not released their patient to return to work.

How many of us have had specific vocational training? How do we know whether our patient can work or not? Do you realize that when you write this down, not only does your patient now believe that they cannot work, but, frequently, the employer will not let the patient work, even if the patient wants to do so. This applies even if the employer wants to accomodate any specific restrictions described.

The bankruptcy and loss of health insurance enters the picture if the disability claim is denied. Often, having been "taken out of work" by the doctor, the employee will not attempt to return to work, or the employer will refuse to allow the employee to return without a release from the physician. In the absence of a finding of disability, the employee will often lose the job. This means losing insurance coverage, unless the employee can purchase continued coverage through COBRA; something they can rarely afford.

The resulting loss of insurance causes debt and, as we have all seen, a patient who cannot afford the care we think they need.

Remember, the patient may not describe their job accurately to you or may be unaware of accomodations the employer may be willing to make.

I recommend you list, as specifically as possibly, what you think you patient can or cannot do, without specific regard to the job they have, and defer an opinion about ability to work to the vocational experts. Don't be afraid to request a Functional Capacity Examination or a vocational analysis by an expert. When asked to give an opinion on ability to work, to quote the lady in red, "Just say no."

We all want to be patient advocates. Sometimes, advocating in favor of our patient's desire not to go to work is not the best for the patient. We are advocates for our children, but don't give them everything they want, do we?

For those readers who will be the patients in this scenario, don't let your doctor write that you can't work. If your condition actually is such that you cannot do your job, and your employer can't/won't accomodate, you will get your benefits even if your doctor doesn't specifically write no work. However, if she does write that, you won't be able to work even if you want to and even if your employer will accomodate.


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