Inside the System

Gaining first hand experience with our health system these past few weeks makes two things very clear: health insurance is absolutely vital to optimal care and the move to electronic health records can’t come soon enough.

The Affordable Care Act ensures that millions of Americans don’t have to forego necessary care. I’m receiving physical therapy for a torn rotator cuff; my orthopedist is hoping to avoid surgery (I’m OK with that). Three times a week I go through numerous exercises at the rehab facility, and do more at home on the off days. The good news is that it’s working.

My insurance pays for several weeks of PT, I’m responsible for just a copay at each visit. Compared with a surgical procedure, the therapy is certainly much more cost-effective.

What if I didn’t have insurance? It’s likely that I would not have seen my primary doctor, if I even had one. Nor received the referral to the orthopedist, gotten the MRI that showed the tear, or undergone therapy. Instead, I would perhaps endure the pain and hope whatever was wrong healed on its own; in the interim maybe making it worse.

If the pain got bad enough, maybe I would have gone to the emergency room and waited for hours to be treated. Without insurance, it’s doubtful that physical therapy would have even been suggested, and since I don’t pitch for the Mets, arthroscopic surgery would likely have been out too. Since the cost of the ER visit is so much greater than a primary care office visit, cost-sharing would have eventually found its way to those with coverage.

If taken to the extreme, perhaps the injury hampers my ability to work. Then I can’t pay taxes on income and wind up on disability. It’s not so far-fetched. It happens dozens of times each day to those without any health coverage.

Later this week I will have some minor foot surgery. It’s an outpatient procedure, requiring no hospital stay. That’s fine with me; I’d rather heal at home. Again, health insurance is the difference between getting the problem fixed or walking around with pain.

My biggest hassle? Filling out essentially the same sets of paperwork with each specialist and facility that I visit. Here’s a perfect scenario where electronic health records work to everyone’s benefit – my medical history, drug allergies, vital signs and insurance information entered one time, at my primary doctor’s office — held securely until other care team members need to access it.

However, electronic health records don’t matter as much if a patient does not have medical insurance. Without it, there is no primary care physician, no specialists, no MRI or X-ray, no physical therapy or corrective surgery. Being in the system instead of outside of it makes a huge difference for what are relatively minor health issues.

Imagine the millions of people with chronic diseases or more serious injuries who go untreated because of cost. Or a sick child whose parents cannot afford a doctor visit. They either go without, or wait until the situation is critical enough to go to the emergency department.

That’s the health system some think doesn’t need fixing.