Sliding scale

During new provider orientation, we were told that the health center organization is doing everything they can to keep patient insurance and payments out of individual interactions with providers. Meaning, that as providers, we shouldn't have to tailor our visit to what insurance the patient has, what they can afford that visit, and what they can afford for future visits as we develop our management plan.This has not been the case. My mind has been completely boggled with getting women the care they want, need, and deserve, on the plans they have, or in many cases, don't have. This is all with the caveat of "unless she has private insurance." All are examples of patients I've seen this week.

• An annual gynecological exam including pap smear and clinical breast exam is free once yearly under a federal or state program. If the woman also wants to be checked for STIs, I can do it the same visit, but if the results are abnormal, she'll have to pay for her return visit to find out the results.
• If the woman believes she has fibroids or I determine there is a reason for a pelvic ultrasound follow-up at her annual visit, she has to pay for that ultrasound, around $200.
• Free pregnancy tests are provided at some clinics. If it's positive, she gets a letter for verification of pregnancy and can apply for public aid. If it's negative, and she's been trying for four years to get pregnant and doesn't know why, she'll have to make a new appointment and pay for the visit for further testing and management.
• If she applies for public aid during pregnancy, it's valid for the full pregnancy and six weeks postpartum. If she doesn't make her six-week appointment (because she has a new baby and is busy), then that's her missed opportunity to get birth control for free, and she'll have to pay for the visit and the birth control.
• Intrauterine devices (IUDs) are no longer covered under the public aid card, so women cannot receive free IUDs postpartum. Tubal ligation is covered, as well as other standard methods like pills and the injection. The IUDs cost between $300 and $500.
• If she has the HMO federal government payment system, some hospitals in the area don't take that. So if she miscarries in early second trimester, the Emergency Room outside of her plan will determine she's miscarrying, will make sure she doesn't have a fever, and will send her to see her OB. When I see her a few days later, she doesn't have her public aid card yet, so has paid for a visit for me to order her blood tests and ultrasound to determine if the miscarriage is complete.

In some ways, ya pagó, already paid, is helpful to me, because then I know I can order any and all tests I want to order. The fee at our clinics is sliding scale, but for some women that sliding scale doesn't amount to how much money they have to spend on healthcare, and every penny counts. Additionally, if proof of income is her husband's income, that doesn't mean that she is provided any money at all in that relationship, to have discretionary spending for her healthcare.On days like yesterday, when I had three patients booked at 3:45 and walk-ins for free pregnancy tests, I wish that part of my visit wasn't being spent figuring out if she already paid, what insurance she has, and what we can do in that visit. But I know that as much as it weighs on my mind, it weighs much more on hers, sliding scale or not.