Dr. Siegel: Even with insurance, patients can't always afford to see a doctor

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All this focus on the need for health insurance would leave anyone to believe that if we have coverage, all our health problems are solved. But my patients and I can tell you that this isn’t the case, and a survey of over 1,000 people released by Bankrate.com this week backs us up.

According to the poll, one-quarter of Americans skip needed health care because of the cost. They may have insurance, but they may choose not to use it — even when they’re sick — because of a high deductible or copay. The patients who choose to forego needed medical care tend to be young: Almost one-third are millennials (ages 18 to 36), and one-quarter are Gen Xers (37 to 52). Millennials are also most likely to go without insurance, especially when their employers ask for out-of-pocket contributions they feel they can’t afford. Of the people who were polled, 13 percent — most of them millennials — didn’t have health insurance.

I am increasingly receiving requests for antibiotics over the phone or by email or text from patients who want to skip paying to see me. I also receive daily requests to renew medications for everything from high blood pressure to attention deficit disorder.

I can’t blame my patients for not wanting to be inconvenienced or to pay for something they can get without charge, but I don’t believe it is good medicine to diagnose bronchitis or strep throat over the phone. For one thing, the infection is frequently viral and doesn’t require antibiotics, whose overuse breeds resistant bacteria, which is a growing problem in the U.S. and around the world. I also don’t believe in excessive prescription renewals without seeing the patient. There isn’t a prescription out there that doesn’t need to be monitored on a regular basis for side effects.

But at the same time, I am sympathetic to the plight of my patients. Premiums, copays and deductibles are rising, and even if patients do decide to pay the copay and deductible to see me for a pressing problem, it doesn’t necessarily mean I will be able to solve it or get them in to see the specialist they need right away for something like a low blood count or a bad shoulder. I have a crackerjack staff of patient advocates who fight for appropriate treatments and referrals, but still there is often a delay.

And if they do get to the right specialist, they will face another copay and perhaps another payment toward a deductible — and even that doesn’t mean the specialist will be able to provide the treatment they need without passing the ball to someone else.

A patient of mine had a urinary infection that was resistant to several antibiotics, and her gynecologist told her to see me for intravenous antibiotics, which I don’t provide and she didn’t need. I prescribed a new antibiotic, but it’s no wonder this patient was reluctant to return to her original doctor for follow-up care, another copay and more out-of-pocket payment toward her deductible.

Deductibles are not adequate brakes on the health care system. All they do is discourage the use of health insurance until they are met. Bankrate didn’t cover a further problem — that once patients meet their deductibles, they may be more inclined to overuse health insurance for things like a common cold or allergy. Not only that, but doctors have no incentive to discourage this overuse, since taking care of the worried well is often easier and less risky. Certainly, if doctors were paid less for seeing patients too frequently, or if the patients paid more, this practice would be discouraged.

The Bankrate survey also found that 56 percent worry that they may not have affordable health insurance in the future. Given the soaring premiums under the so-called Affordable Care Act and with no definite prospect of reducing premiums with a new law, their concerns are certainly legitimate.

Proposed high-risk pools for the sickest patients could reduce premiums for the rest of us, as could introducing an option to buy catastrophic insurance. Instead of relying exclusively on cost sharing, the government could pay directly for some essential care by adequately funding risk pools and supplementing the costs of items like maternity care and mental health and cancer screening. Expanded tax-free health savings accounts could help the middle class pay for basic services.

But the main solution to the false promise of health insurance is to refocus our attention on access to actual health care, rather than simply assuming that our insurance will bring us there.