An Interview with Dr Rajagopal, MD, a Family Physician in the US

Here’s a sneak peak into the IG live interview session I had with Dr Rajagopal, MD. Find the full interview on my instagram page, @apothekathryn

Q: Tell us a little bit about yourself!

My name is Thivisha Rajagopal, but usually my patients call me Doctor Raj. I am a primary care physician, which I think you call a GP in the UK. I’ve just finished my first year as an attending. As a primary care physician, I see all kinds of patients of all ages. I deal with Women's Health in particular, so I talk to a lot of women about birth control, OB care, IUDs, PAP smears and all of that stuff, but at the same time, I also take care of chronic medical problems like heart failure, blood pressure, diabetes as well as people who come in with a cold, flu or sinus throughout the day.

Q: Could you tell us a bit about how the healthcare system works in the US?

I'm a Canadian, so I know how it works in Canada and how it differs from the US, which is where I'm practicing. In the US, the way it works is that the majority of patients (over 60%) have private insurance. There are subcategories of different types of insurance that patients buy from companies, which all depends on what kind of income they bring in and the kind of budget they have for insurance. On the other side, you have people with lower incomes who qualify for something called Medicaid and then you also have people that are over 65 that have Medicare. Some people can have a combination of the two, but this is generally the outline of insurance types that people have.

Q: Are there ever people who don’t fall into either of these categories and hence cannot receive care?

If they’re not able to have one of the insurance types, they’re pretty much paying out of pocket. So, depending on their visit, they’re paying cash when they check in and check out. It will be very obvious to us and our front staff will tell us that the patient is self-paying. When we have such patients, we try and do the maximum during that visit, because we know that they will not be able to come back again for an additional visit, as it would mean an extra cost for them.

Q: What are some aspects of the Medical system that you think could be improved?

When patients have insurance, it doesn’t mean that everything is covered. They might just have basic coverage, with them having to pay out-of-pocket for anything additional. For example, if they suddenly need to be admitted to the hospital, they will walk away with a huge bill that they have to pay, and they’ll probably be paying for it for the next five to ten years of their life, because the bills are huge and could be over $10,000 or $20,000, just for a 3 day hospital stay. When I had my baby and was in the hospital, I did have insurance, but I had a high-deductible -- meaning you have to pay a certain amount before the insurance will start to cover the costs, so I had to pay about $2000 out-of-pocket before the insurance took over to cover the costs for the delivery. It's really hard for us because we’re limited by what we can do if patients don’t have insurance. For example, if I have a patient with Diabetes that is out of control, I prescribe them Insulin. However, sometimes they can’t afford it, and their insurance will also come back to say that the medication required is not covered and that the patient can only choose between a few medications. These medications that insurance covers don't always give patients the treatment that they really need.That's one of the things that's frustrating as a Physician because we’re limited by what we can prescribe to the patient because of the confinements of insurance

Q: Do you think that the US could benefit from a medical system where everything was free at the point of the delivery? (kind of like the NHS in the UK)

I think Canada has a very similar system to the UK. In Canada, I wouldn’t say it’s free, but it’s funded and covered. Everyone who lives in Canada has a health card that allows you to go to the ER for an emergency or to go get a primary care doctor, without having to pay a large bill. You might have to pay for certain medications or for certain tests, but the basic care is covered. I don't think that the US will ever go under such a system (like the NHS where everything is free at the point of delivery) because we are very different countries. Even in Canada, there are Pros and Cons to having it. You always have to look at the other side. Because I’m a Canadian, I know what it’s like to live there and see a doctor. It's not easy to get a primary care doctor in Canada, because they're all booked and they have a certain cap of patients that they can take because they just don’t have any more room for more patients. This becomes a problem when there's a huge waiting list of people to be seen by a doctor, with it being even harder to see a specialist. When my mom had to see a cardiologist, she was on the waitlist for 3 months, which is an example of how long it can take to see a specialist in Canada. Comparatively, in the US I could have gotten my mum to see a cardiologist within a month. There are huge pros and cons to each system. When you're sick, you want to be seen by a Doctor quickly, but you also don’t want to walk away with a giant bill. I really don't think the US will ever go on to that kind of system (UK’s kind of system). If it does, it will definitely be very different.

K: It’s so interesting to see how each country has their own health system that is the most suitable for them!

Q: Have you ever experienced patients who aren't willing to pay for medical treatment and so just refuse care?

Yes. The responsibility to seek and pay for healthcare is on the patient. Not everybody is rich, and people that are rich are already able to afford private insurance that covers most things. The people that are not able to have health insurance are the ones that do not have a good income and hence the slightest income that they do have is not used to see a doctor. Some patients like this do eventually come to us, but they're often already in very late stages of the disease. There’s so much we need to do for them, but when we tell them what treatments they need, they’ll refuse because of the costs associated with it.

Q: Is there any way that you can handle these situations?

It's really hard and it depends. For example, if they were admitted to a hospital, some hospitals do take charge of the bill, or a certain percentage of it. However, some hospitals don’t. It is a sad reality we live in, but that's how it is.

Q: Are all the hospitals in the US interconnected? Is it easy to get referred?

It depends. In my hospital, the staff are all connected and we have a back line text message system. For example, if I have a patient, who has a rash I'm not sure of, I can take a picture which I then send to a dermatologist in the hospital. It's a secured network and is confidential. Once I send the text he can then quickly advise me on what to do. In this way, I'm saving my patient from having to see a specialist, which is an extra visit and payment. In the same way, If i need to do a referral to a specialist, but I think that they need to be seen quicker, I can send them a message to say that I'm worried about the patient and request that they see the patient sooner. The specialist will then push that patient further up on their schedule and get them in sooner.

Q: How has your job been affected by Covid-19?

The Covid outbreak probably happened here around mid march. I started out as an attending in December and was just starting to pick up patients because I was new in the area. When Covid happened, everyone was taken out of the office, because there was not enough PPE to go round, and the PPE that was available was to be saved for the hospital and the ICU. In the beginning, we had no idea how we were going to see our patients. However, telehealth then came out which allowed us to do appointments by phone call. There were a lot of glitches in the beginning and a lot of things to sort out, but we eventually got used to it. At the same time, I was able to do a lot. I could treat migraines, headaches, flus and help to manage things like blood pressure just over the phone. When I started doing telehealth full time, it was pretty tiring not seeing patients eye to eye as we couldn't do physical examinations and could only talk to patients. We had to make decisions like whether the patient was sick enough to go to the hospital or if the problem could be solved over the phone just by looking and talking to the patient. We try very hard to minimise people going to the ER as it is very dedicated to Covid at the moment. Hopefully we can go back to the office soon since the vaccine is out, but it’s still going to take time.

K: Thank you very much for answering all my questions! It was really interesting and gave me such a good insight into the healthcare system in the US. For the full interview, check out the IG live on my instagram page, @apothekathryn. Dr Rajagopal’s instagram page is @dr.thivisha.raj Make sure to check it out!


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