At my office we provide care for a fair number of patients without medical insurance. Sometimes we are faced situations with no good options.

At a patient visit, often times the diagnosis is not clear without doing some diagnostic tests other than the history and physical exam. Many of these tests are ordered from sources outside the office, where I have little or no control over the cost of the test to the patient. In other than straightforward visits, where the diagnosis is apparent and treatment can be recommended from what is learned at the visit, these tests can cost more than the charges from my office.

The old saying, “The most expensive medical instrument is the physicians pen,” is true in these cases. The dilemma is that I know ordering these creates a real problem for some of my uninsured patients. When do I order the CT scan to look for an atypical presentation of appendicitis in the 23-year old woman who probably has a simple ovarian cyst, but could have a ruptured appendix? When do I order the MRI looking for the unlikely but possible brain tumor in the 25-year old with severe headaches for 6 weeks who likely has stress headaches?

We use a program called “Simple Care” to avoid contractual issues with our third party payers, both governmental like Medicare and Medicaid, and private insurers. Simple Care patients are required to pay at the time of the visit, saving us the need to bill, collect, and code for the visit. We have convinced our lab and primary radiology referral sources to discount their services to our Simple Care patients.

This works well for most visits, but when a patient has a potentially serious problem where the standard of care is to order tests outside the office it gets complicated. The patient may be able to afford the $50 or $60 dollar visit, but the $1500 CT scan or MRI, or the several hundred dollars of lab tests may be another matter altogether. Few of my specialist consultants discount fees for cash paying patients, and these patients often do not have the cash to pay at the time of service for more expensive tests, consultations, or procedures.

In some cases I can feel comfortable using time, therapeutic trials, and inexpensive tests to get to a diagnosis of exclude more serious problems. Other times the diagnostic possibilities include problems so serious that delay in diagnosis puts the patient at such risk that I have to strongly request they spend the money, of more often incur the debt to get the tests done.

It is easy to argue that a physician just needs to provide the same level of care for the uninsured patient as the insured patient, but in the world we live in the consequences of subjecting the patient to debt payments for months or years, or possibly bankruptcy has to be taken into account. The chances of a negative test are usually higher than the chances of a test showing the problem you are looking to exclude or confirm.

In these cases I sometimes second guess myself. Could I have safely avoided exposing my patient to the expense of these tests that turned out negative? I don’t have an answer for this dilemma. I try to give a recommendation, present options, and involve the patient in the solution.

Still I struggle often with the responsibility of urging a patient to get testing I know they can neither afford to have done or to not have done.

Edward Pullen is a family physician who blogs at DrPullen.com A medical blog for the informed patient.

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