Insurance may not be enough

In the practice of medicine, as in any human endeavor, we encounter a wide variety of human beings.  While thinking about this recently, in light of the passage of the health-care reform act, I realized something startling, that supporters of the bill may not realize.  There are some patients that nobody wants to see.

This uncomfortable truth exists irrespective of the presence, or absence of insurance.  Sometimes physicians are accused of dismissing, or avoiding, certain patient on the basis of their finances alone.  While that problem exists (and I have seen it), a great many of the patients who can’t find (or keep) physicians simply aren’t much fun to be around…much less treat.

It’s really far too simplistic; this idea that infusions of money or entitlement will fix every problem.  Witness the American public school system if you need verification.  But it’s dangerously naive to assume that all one needs to find a doctor is an insurance card. 

There are so many patients who are unkind, difficult, drug-seeking, disability craving and non-compliant.  They demand early refills on narcotics; they demand the latest therapy or drug, however unproven.  When admitted, they curse the nurses and harrass their providers.  When they come to the emergency department, their tolerance for narcotics is the stuff of epics.  They fuss and fume when they aren’t taken seriously, then cuss and fume when they are because they are tired of waiting and want to leave.  Despite heart disease, they smoke.  Despite liver disease, they drink.  And yet, our future compensation, especially in primary care, may well be tied to physicans’ success or failures in treating people who simply won’t listen.  (A thing that is manifestly unfair and extremely myopic and idealistic.)

Many patients will benefit from insurance.  Hopefully the majority will see it as an addition to their lives which will require their participation for a healthy outcome.  But some, a loud, difficult minority, will simply consider it one more entitlement.  All the worse with that much publicized policy in hand.

Having insurance, unless it pays for widespread personality transplants, won’t make it any easier for certain unpleasant individuals to find or keep a doctor.  And it certainly won’t make it any easier to take care of them, in sickness or in health.