Respond to the two student discussion post 1-2 paragraphs for each.
Reply to each students discussion post 1-2 paragraphs. Your responses to peers need to be substantive, with constructive suggestions, critique, or insights. You are expected to use in-text citations and list of references to support your posts.
Week 3 Discussion
Adilene Mendoza-Pelayo
A patient who has a severe but undiagnosed disease, illness, or injury would have to go through a long process to be diagnosed. To be diagnosed, a patient should first schedule an appointment with their primary care provider. Their primary care provider will assess them and order tests and or imaging to confirm their preliminary diagnosis. Once the provider determines the diagnosis it might also be necessary to refer the patient to see a specialist. For instance, a patient has severe back pain & get diagnosed with pinched nerves, then they will be referred to a general surgeon to have Spinal decompression. As explained by Radman & Eshghi,
According to physicians opinion, because of the multifaceted nature of most diseases, patients should be observed by different specialists during their treatment period (Radman & Eshghi, 2018)
Furthermore, the barriers and challenges that a person might face are many: the doctor that they want might not be in network with their insurance, the specialist might be far away from them, they might have a large co-pay, and their appointments might have to be rescheduled. Also, the patients conditions might worsen since the wait will be long. There is also the issue of referral noncompliance. As presented by Van Dijk, Referral non-compliance could delay diagnosis and treatment (Van Dijk et al, 2016). With settings in high quality a patients experience will differ from a low-quality place as in a high-quality setting, in the way that navigating the healthcare settings will be easier in a high quality place. Also, in a low-quality clinic a patient can be misdiagnosed, they can be referred to a specialist out of network resulting in higher costs for the patient.
Jims experience was a little rough in the sense that the diagnosing part took a long time, and he was referred to physical therapy place that was far away. However, his experience could have been worse. I worked at a clinic where a patient was referred to a specialist that was out of network and he had to pay a high out of pocket cost as his insurance covered a smaller percentage for going out of network.
van Dijk, de Jong, J. D., Verheij, R. A., Jansen, T., Korevaar, J. C., & de Bakker, D. . (2016).
Compliance with referrals to medical specialist care: Patient and general practice
determinants: a cross-sectional study. BMC Family Practice, 17(1), 1111.
https://doi.org/10.1186/s12875-016-0401-7
Radman, & Eshghi, K. (2018). Designing a multi-service healthcare network based
on the impact of patients flow among medical services. OR Spectrum, 40(3), 637678.
https://doi.org/10.1007/s00291-018-0519-1
Doug DQ 3/1
Doug McLaughlin
To Disease, or Not to Disease, That is the Insurance
In my scenario we have a 25 year old female complaining of left flank pain along with painful urination. She has tried to get into her Primary Care Manager (PCM) for 2 weeks now but the first available is in 2 more weeks. They recommend going to the Emergency Department (ED) for evaluation and pain management. She tries to bear through the pain, but decides to go 3 days later. Checking into the ED is quick but she waits three hours in the waiting room then another two waiting for the doctor and labs, etc. The doctor in short tells her shes fine and its probably to do with her anxiety shes dealt with all her life. He denies her request for imaging at this time. Note that she has insurance at a university health system and the ED is at the University. She goes home feeling dejected, unheard, and still in pain without proper diagnosis. This cycle repeats four different times at the ED over the next months. Her PCM referred her (without exam) to urology at the university. She went back numerous times, each one a different male doctor and each time he rather dismissed her symptoms. They did finally do CT scans and noted a defect, however did nothing. Eventually, her kidney has swollen to three times a normal size with 15% function. Her back constantly hurts and urinating is a slow trickle most days. She makes one more attempt at an Urology appointment. Her fear is finally realized. While not admitting malpractice, the Urologist says the kidney could have been saved early on, but now at 28 years old, she will be living with one kidney.
Two years later, her scars are visible when she wears crop tops, but the worst scars can not be seen. Her PTSD and anxiety ramp up before every doctors appointment and some days she can not get out of bed to care for her two boys. She is certain that she was not taken seriously because she was a young, attractive, female.
Money Wasted
I found a breakdown for outpatient visits for a total around $1000 (OC Urology, 2022), but I do not know the extent of labs, ultrasounds, etc performed. The best breakdown I could find for fees of the surgery was from 2003 and it would have cost $28,203 (Lotan et al., 2003). These numbers were from a county hospital in the USA, but no other information was noted. I would not be surprised if the same operation here in southern California cost double that number today.
Had she been uninsured, I am not sure how this scenario would have played out. She probably would have only gone to one urologist visit and accepted the answer. She would have continued to lose kidney function, and had to have her kidney removed anyways, maybe taking out a bank loan for the surgery. Or maybe the ED physician would have heard her, done the proper procedures, and saved the kidney from the beginning, $1000 problem solved.
With Jims scenario, his insurance failed him due to location of services. All the services he needed were hours away, adding avoidable stress to his situation. Jim should have done his due diligence when selecting his policy to see where the nearest services were. It is also possible that his insurance dropped services closer to him recently.
References
Lotan, Y., Gettman, M. T., Roehrborn, C. G., Pearle, M. S., & Cadeddu, J. A. (2003, June). Laparoscopic nephrectomy is cost effective compared with open nephrectomy in a large County Hospital. JSLS : Journal of the Society of Laparoendoscopic Surgeons. Retrieved March 14, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015483/
OC Urology. (2022, March 7). Billing & Insurance: OC Urology in Santa Ana, CA. OC Urology. Retrieved March 14, 2022, from https://ocurology.com/billing-insurance/
