Doctors and patients traditionally have not discussed the cost of health care. But that's beginning to change, as doctors recognize that value is an important part of high-quality care. At St. John's Well Child and Family Center in South Los Angeles, one doctor has learned that discussing cost is critical to improving the health of poor, diabetic patients.
On a recent morning, several dozen Latina women gather at the clinic for a weekly diabetes class. They eat a healthy breakfast and then turn on some music and dance for exercise.
Dr. Shom Dasgupta, director of social medicine and health equity at St. John's, sits at a nearby table and holds one-on-one meetings with patients. The class atmosphere is festive, but when Dasgupta talks with 56-year-old Rosa Aviles, their conversation is far from light-hearted party chitchat.
Facing 'reality of what their economic situation is'
Aviles admits that while she owns a glucose monitor, it's been months since she used it to check her blood sugar levels. The reason, she says, is she can't afford the co-pays for the monitor's test strips. This means she's been using insulin, but she has no way of knowing how it's affecting her blood sugar. And this is dangerous: She could use too much insulin and go into diabetic shock.
For Dasgupta, the morning's festivities become less of a dance party and more of a scavenger hunt. He makes a beeline to the clinic's pharmacy, where he searches for a glucose monitor and several months' worth of test strips.
As a short-term solution, he'll send Aviles home with this equipment at no charge. He also writes Aviles a prescription for a generic-brand monitor and strips that should be fully covered by her insurance. But it could take a while for the prescription to be processed, and he doesn't want her to go any longer without testing her blood sugar at home.
While some doctors shy away from talking about the cost of medications, Dasgupta says sometimes cost is directly related to medical outcomes, like in Aviles' case.
"We could just write the patient off as ... non-compliant, refusing to face reality about their diabetes, but if we do that, then we miss the opportunity to face the reality of what their economic situation is," Dasgupta says.
'Don't want them be taken advantage of'
When he returns from the pharmacy, Dasgupta asks Aviles about any natural medicines she's taking.
She replies that when she has a stomach ache, she drinks teas made from oregano, yerba buena and rue. He warns her against consuming rue, also known as Herb of Grace, explaining that it could cause kidney damage.
Then Dasgupta probes further, asking where she buys the herbs and how much they cost. She looks puzzled by the questions, so he explains that many of his patients rely on natural or alternative remedies that can be costly. Dasgupta tells her he just wants to ensure that his patients aren’t getting ripped off.
Ignoring this possibility, he says, would mean ignoring the daily decisions people make when trying to improve their health.
"It's totally fine if it's an innocuous or potentially helpful medication that they're growing at home," he explains. "But if they're spending $6 a day, have no income, on special shakes sold by a nutraceutical company, I don't want them to be taken advantage of."
This happens often enough that dietician Ivy Marx addresses it during the diabetes class. The dancing has died down, and the women sit in a circle. Marx points out a classmate who recently lost weight, without buying Herbalife shakes.
Instead, Marx says, the woman did it by cutting down on junk food and switching to a more balanced diet. Marx says long-term, this is a healthier – and more affordable – approach.
After the class, another patient, 58-year-old Maria Catalina Zarate, says she takes the doctor's lessons with a grain of salt. She says she’s poor so everything seems expensive - including healthy vegetables, natural medicines and a gym membership.
But, she says, if she thinks something will really improve her health, she’ll consider buying it.