Making Up the Difference: Otolaryngologists find ways to provide care for under- and uninsured patients

Doctors Rima and Robert DeFatta, married otolaryngologists who work at Sacred Heart Hospital in Eau Claire, Wisconsin, spend about an hour each day dealing with insurance-related hassles. About 20 percent of their patients are un- or underinsured, so the two physicians spend time dashing off letters to insurance companies, re-jiggering treatment plans and helping patients access available resources. Recently, Rima DeFatta, MD, had to figure out how to diagnose a patient who presented with symptoms that suggested possible neurologic involvement.

“My patient only has major medical coverage, so I’m trying to figure out how to accomplish accurately diagnosing him with studies that may not be optimal to diagnose his pathology,” she said. Her husband, Robert DeFatta, MD, PhD, works with head and neck cancer patients; he’s often frustrated by insurance companies’ refusal to pay for effective pain medication or to cover cancer-preventing vaccines.

Their experience is not unique. According to the Kaiser Commission on Medicaid and the Uninsured, there are close to 50 million uninsured Americans. Millions more are underinsured, and the lack of adequate insurance is affecting care. A recent study of 155 patients who discontinued treatment for allergic rhinitis revealed that 40 percent discontinued subcutaneous allergen immunotherapy due to inadequate or nonexistent insurance coverage (ENT J. 2011;90(4):170-173). Other studies have correlated poor asthma control with lack of adequate insurance (J Gen Intern Med. 2002;17(12):905-913; Pediatrics. 2006;117(2):486-496).

Recent government reforms, most notably the Affordable Care Act, are meant to address the growing problem of un- and underinsured patients, but it “remains unclear if government solutions are going to be either effective or lasting in terms of solving the problem,” said Urjeet Patel, MD, associate professor at Northwestern University and chair of otolaryngology at Cook County Hospital in Chicago. In the meantime, individual otolaryngologists are left to figure out how to provide quality care to patients who may not be able to afford it.

Access to Care

Lacking comprehensive insurance, many patients forgo routine physicals and preventative care. As a result, otolaryngologists may see more patients with advanced disease. Dr. Patel, who sees patients at both Northwestern University and Chicago’s Cook County Hospital, has noted that head and neck cancer patients who present to Cook County, a publicly funded institution, tend to have more advanced disease than those who present at Northwestern. In one study of 209 patients, 68 percent of the head and neck cancer patients at Cook County presented with Stage IV disease; 16 percent were Stage III (Laryngoscope. 2006;116(8):1473-1477).