BGUH (part deux)

We spent another day at Beirut Government University Hospital, and had the opportunity to meet with the medical director and attend morning report.

Just as in the US, a significant percentage of Lebanese have private insurance, but the uninsured and the underinsured populations remain significant. The government insurance scheme does not cover outpatient care. There are discounted clinics (including at BGUH) where physician visits are more affordable, but patients are limited in their ability to pay for bloodwork or imaging tests. They are building new outpatient clinics at BGUH but the director told us that there is still no funding for ongoing patient care.

Many patients come to the ED for admission because they cant afford routine outpatient care. Furthermore, private hospitals severely limit their capacity to admit underinsured patients by limiting the available beds in the hospital. One of the hospitals we visited earlier reportedly has only 10 beds out of over 400 reserved for patients with the government insurance plan. Underinsured patients at private hospitals either wait for days in the ED for beds to become available or get transferred to the government hospitals.

BGUH is a modern tertiary-care hospital with an ICU, cardiac catheterization lab, PICU, etc. Its 400 beds are always at capacity, making it many times busier than the next largest government hospital. In spite of excellent facilities, the hospital is chronically underfunded, often without enough money for blood tests or radiologic studies, and loses 15-20 million USD annually. Government funds are often distributed based on political needs rather than medical needs with monies going to outlying regions of the country to show governmental support for those districts.

The morning report was mostly remarkable for how similar it was to our own. The case was an elderly man presenting with painless jaundice and weight loss who was being evaluated for likely pancreatic cancer. The discussion was identical to one we might have at Columbia including choosing appropriate blood tests and imaging modalities. Perhaps one difference was the greater emphasis on concepts of efficiency and cost-effectiveness. The patient had pre-renal azotemia and the initial debate was whether an abdominal ultrasound or a CT with contrast would be the preferred study based on safety, utility, and cost. Later we learned that the patient had undergone a non-contrast abdominal CT at an outside hospital a few months ago that was reportedly unremarkable. Now the thought was whether the additional time and expense of an MRI would be beneficial.

A nurse interrupted the presentation with a printed sheet of paper. This was the daily report of which tests had been approved by the government insurance for that day. Of the 15 items, perhaps one third to half had been rejected, including things as simple as a TSH assay. Cancer markers for a patient with a known mass were denied, as was a brain MRI for an individual with persistently altered mental status with negative workup including two unremarkable CSF examinations. The residents regularly spend hours speaking with the insurance companies to get these tests covered.

For our case, the team had decided on the MR scan, but we found out from the daily report that day that the request for his MRI abdomen was approved, but the MRCP was denied.