And now the rest of the story

Two weeks ago, Perspective published an essay by a Hudson orthopedic surgeon about his experience treating an uninsured 21-year-old woman who limped into his office with torn knee cartilage but turned out to have something far more serious: a large brain tumor.

Dr. Craig R. Bennett's column, coming against the backdrop of the national health care debate, touched on everything from the fading art of the diagnostic exam to the charity of the medical profession and the natural limits of that charity.

It also raised questions: How was her serious medical condition missed? And once it was discovered, who should foot the expensive bill to treat a very sick patient who can't pay on her own? How many times can society afford to pay? How could it not?

Those questions were left unanswered, as was this one: Who was this patient?

Her name is Richelle Haag. She lives with her mother, Cindy, a dog groomer, in the west Pasco County neighborhood of Embassy Hills. Cindy called the Times to identify her daughter as the patient and to publicly thank Bennett for saving her daughter's life.

Richelle has lived here all but four years of her life, when as a teenager she went to live with her father in Ohio. She studied science in community college but dropped out and returned home to her mother earlier this year.

Back in Pasco, she found a $10-an-hour job with a "loss mitigation company" ("We helped people who were behind on their mortgages," she said). But the company did not offer full health insurance, only a supplemental plan.

And on $10 an hour? The plan didn't provide enough coverage to justify the costs, Haag decided, especially when she had a car payment and a cell phone bill. She'd never been sick, anyway.

More than a month ago, the left side of her body started feeling numb. First her toes, then her foot, then her whole leg.

She went to a walk-in clinic in Palm Harbor. The doctor told her not to worry. " 'We don't want to do an MRI,' " her mother recalled the doctor saying. " 'It's too expensive, and you can't afford that.' He didn't make it sound like a big deal."

Haag started using a crutch, and she got on the Internet. Maybe it was a pinched nerve? "We were playing scientists," her mother said, with a sigh.

Next came a three-hour wait in a local emergency room (no diagnosis but she got a lumbar MRI and a referral to a local clinic) and later, three more MRIs on her hip, knee and ankle. One of those tests revealed a problem: A torn meniscus.

That didn't explain the numbness. No matter: Haag and her mother figured this was the closest thing they'd had to a real answer to her problems.

Bennett's office agreed to take on her case, even though she has no insurance, and a patient-care coordinator there worked to get them in as soon as possible. The coordinator, seeing that Haag had little money, worked with her, too, to get the emergency room bills put on hold for a year.

Haag and her mother arrived on a recent Friday, after both of them got off work, to see the doctor for a consultation and set up an appointment for knee surgery.

Only, as Bennett wrote two weeks ago, things didn't turn out that way: One of his physician's assistants realized that Haag's exam was "off," that the numbness she described wasn't something associated with a meniscal tear. He fetched Bennett, who performed an in-depth physical exam, saw signs that her spinal cord was affected and ordered an emergency MRI.

So it was back to the same hospital where she got her first MRI. The technician kept coming back to Richelle, saying he'd need to take more pictures. She asked him what he saw and he said she'd have to talk to the doctor. By the time her mother saw her again, she was sitting in a wheelchair, eyes bloodshot from crying. They went into an exam room and waited for the doctor to take in the official news together: She had a 5-centimeter tumor on her brain. Maybe it'd started a year, a year and half ago. The diagnosis: glioblastoma, an aggressive brain cancer. It was in Stage 4.

"It's kind of a blur after that," said Richelle.

That night, a Friday, an ambulance drove her to Mease Dunedin Hospital. Her mother said they wanted to keep a check on her vital signs and make sure she didn't have a seizure.

Three days later, she had brain surgery to remove the tumor. Her face was swollen, her right arm wouldn't work right. Her mother cringed when Richelle cried out in pain as the staff moved her neck.

Not quite a week later, she left the hospital.

Since she could no longer work, she began for the first time applying for disability and food stamps. With discharge papers in hand, she could finally apply for Medicaid.

Amid all this was a treatment schedule that has already filled the days in her mother's new blue calendar book: six weeks of chemotherapy and radiation.

By her own account, Richelle has so far received mostly excellent care since Bennett first examined her. Doctors and nurses took to the young woman with the long auburn hair, sweet disposition, droll sense of humor. She was just a kid, dealing with a deadly brain cancer similar to the one that killed Sen. Edward Kennedy.

Richelle didn't want to know how long doctors thought she had to live. "Nobody's God," she told her mother. Cindy privately asked the doctors what they thought, but she didn't believe their verdict, either; Richelle has youth on her side.

Still, Cindy can't bear to think of how fast Richelle might have deteriorated had Bennett not ordered the emergency MRIs when he did.

"If it wasn't for him … Oh, good God. There are no words," she said. "Thank God that a doctor paid attention to details. He went the extra mile."

But the medical care comes with a price tag that Richelle has no hopes of paying. She's tallied most of the bills, and the cost is well over $165,000.

So far, she hasn't paid any of that. Her doctors are going on faith that she'll qualify for Medicaid. Her chemotherapy clinic found an organization willing to pay the $7,000 for this first round.

Cindy keeps every bill together in one neat pile. Someone told her there's a form she can send, saying that Medicaid is on the way. But no one has sent her the form, so she just stores the bills in a clear folder with pink trim, the same folder that houses Richelle's food-stamp application, disability papers and cancer research reports.

How close Haag is to getting Medicaid is unclear. She's tried calling. She's waited on hold for hours, left messages with three different people when their voice mails weren't already full. No one has bothered to call her back.

What, if anything, does Haag's experience say about what health reform should look like? Haag and her mother say they haven't followed the debate too closely.

Haag would like a chance to buy affordable health insurance. She also says that Medicaid should prioritize the very sick and should be easier to deal with. Her mother said she left a voice mail at the White House with the same message.

For Bennett, Haag's case shows the charity that hospitals and doctors provide on a regular basis.

"Overall, I think the health care system worked out pretty well," he said.

Even if Medicaid comes through, he pointed out, it reimburses very little of the costs. "Most of the doctors will eat that," he said.

And Richelle would likely stay on Medicaid. With brain cancer as a pre-existing condition, he pointed out, what private insurer would cover her?

"The positive side of this: There really is a way for anybody to get help," he said. "Our system does a lot to protect people without any money."

But is it the system, or individuals? Did Richelle just happen to come across the right people, from the woman who made sure she got in to see Bennett to the woman in the chemotherapy center who found a program to pay her first round?

"Well, that's how life works," said Bennett. "It's hard to codify how people act. Life is a little bit of luck."

But kindness isn't a sustainable business plan. Or as Bennett put it: "I can't treat a hundred Richelles."

And how much more luck Richelle will need for future treatment is uncertain.

Already, she's had a hard time finding a primary care doctor who'll take Medicaid, let alone someone waiting on Medicaid. She's going to need physical therapy, which Bennett says he'll provide for free. The Haags still worry, but what they worry about has changed.

"So if you drop your cell phone and it breaks, it's okay," said Cindy. "Oh, I don't know. What am I trying to say?"

"The petty things don't matter," said Richelle.

"Right," said her mother. "The petty things don't matter."

Jodie Tillman can be reached at jtillman@sptimes.com or (727) 869-6247.

And now the rest of the story 11/09/09 [Last modified: Monday, November 9, 2009 10:17am]

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