Medicine and money; why is it such a problem?
Wow, what a contentious combination. Medicine and money. What do we do about it? It’s generally agreed that medical care is expensive. It’s generally true that physician payment accounts for a fairly small percentage of the overall cost. Most folks agree that difficult jobs should be more heavily compensated than easy jobs.
Everyone wants a really good doctor. Every doctor, who spent a long time listening to boring lectures, consuming too much caffeine and being up all night, really wants to make a good living. Nobody is in line for the ‘Medical Dollar Store: All care one dollar or less!’ Everyone wants access to the best care. Nobody wants accidents, errors, or care that is not based on the latest research. Everyone would like their doctor to be available…a lot. Many people would love for medicine to be heavily computerized so that EMR (electronic medical records) were a standard feature of practices. We all really want private rooms in modern facilities. We would love for our children to have every specialist necessary to get them through their crises.
Nobody wants to be denied access to a medication they need because it is too expensive. Nobody wants to hear that there was a medicine, but it was just too expensive to manufacture and test, so it never came to the market. Nobody wants to be denied costly surgeries. We don’t go to the hospital to hear ‘Sorry, but odds are you’re going to die. We could fix you, but it just cost a lot, so we won’t. Don’t be bitter, you’re helping the economy!’
Everyone wants insurance that’s affordable, and that provides all things to all people at all times. Everyone wants that insurance to pay for physicians in such a way that those physicians are available, to all people, at all times.
But very few people are willing to recognize the nasty common denominator for all of that care and access, all of that modernity and science, all of that hope and comfort in misery. The common denominator, my medical mathematicians, is money. Cash, cold and hard. L’argent. Pecuniae. Scratch. Dough. Currency.
Money drives the medical world, like it or not. Well, I should say, money under-girds the hard realities of the medical world. (I like to dream that we still do it for love of our fellow-man, in addition to love of supporting ourselves with honest work.) Medicine is that rare modern commodity that everyone wants, everyone needs and everyone agrees should cost less.
By comparison? My car runs on gasoline. When I get it, I know I have to pay for it. There is no negotiation allowed at the gas pump. No promise to pay. No ‘gas insurance.’ If there was, heaven help us; gas would be $250 per gallon! My vehicle uses gas and takes my family where they need, and want, to go. And it drives me to and from my place of employment. I have to pay for it. Crazy! Money and fuel/transportation? Neanderthal.
My house shelters my family. I can’t decide not to pay the mortgage. As we are seeing with the mortgage crisis and the foreclosure rates, banks have no sense of duty to give any of us a house. Don’t pay? Someone else gets the keys. Money and homes? Shocking.
I need food, and so does my family. Oddly, at the checkout, I have to pay for it. No one pretends that its free. Even food stamps, people realize, represent an amount of cash. Not a discounted rate, but a fixed amount of money. You can’t leave the store without paying. Money and food? Gastly.
I have friends and family in the law. We all need justice. I’ve required attorneys in the past. They’re brilliant. I love my sister-in-law and my dear friends who are lawyers. They like to be paid. They have to be paid. We need justice, but justice may require payment? Inconceivable!
Why is it so odd to assume that health-care requires good compensation? Why is it so shocking and disturbing that it’s expensive? In a post-modern world where so many have decided that the next life is ‘un-scientific’ and therefore unlikely, it only makes sense that our culture has responded by trying to prolong and improve this one at every possible cost.
Why do so many physicians, particularly those on the salaries of large groups or institutions, like to talk about providing free care? Care isn’t free. Care can’t ever be free. It might be free to someone, but someone is always paying on the other end.
Lately, I’ve seen more than my usual rate of individuals who say, ‘I came to the ER because I owe my doctor money.’ ‘I came here because I can’t afford to see the surgeon.’ ‘I came here because it’s too expensive at the dentist.’ ‘I came here because I can’t pay anything.’
I’m sympathetic. I don’t turn a deaf ear to them. I don’t hate them or despise them. Jesus said ‘In as much as you have done it unto the least of these, you have done it unto me.’ I want to help. I write off bills. I accept that many patients won’t pay. I love knowing I can help the ones who can’t help themselves.
But where else is that acceptable? We can’t go to the gas station, the mortgage-holder, the grocery store, the car dealer and say ‘I’m here for food, car, gas, etc. because I can’t pay for it. I need you to give it to me.’ Well, we can do it, but under what circumstances are they compelled by law to do that?
My real problem is that our national perception of reality is so clouded. None of those businesses will give me things for free. What’s more, it’s unlikely that the people I see for free would turn around and do the same favor for me if I came to their business. Their reason? ‘You’re a doctor. You can pay! You have money!’
Do I? Do you? Did we get that big bag of money at graduation? Medicine is a high calling, a great profession. It’s a place of service and ministry, and a place of overt and covert mission work. But it’s a place of business as well. And it can’t give things away, as it does day after day after day, and be expected to carry on like it always has. That’s simply fuzzy logic and irresponsible governance.
We cannot treat medicine as the thing we want the very best of, and are willing to pay the very least for. And we can’t, as a culture, make hospitals work on shoe-string budgets and physicians work for falling payments and hope to have the best of the best at every visit. We can’t expect doctors to pay to see patients; but we do, because we pay malpractice for every patient we see, along with paying for billing, transcription, over-head, office costs and all the rest.
The answer? I don’t know. But ‘provider taxes,’ wherein we make more but get taxed more, are a despicable deception. Nationalization? It may increase access, but to what? To primary care? To specialists? To procedures? Not if everyone wants the same high-quality, high price-tag care.
How about cutting out layers of administrative and legislative oversight? How about simplifying the billing processes? How about more tort-reform? How about letting doctors make decisions, rather than having organizations and committees force their hands?
I don’t know what we need, but I know what I want. What I want most of all is honesty. I want us to all, collectively, say ‘Yes, it’s expensive. Very good things often are.’
I want us to be the best we can be. But I don’t want to hear anymore about ‘free anything.’
We might be able to make it cheaper and more available. Maybe. But it sure won’t ever be free.
Edwin
The whole American health care system is based on money. Just look at the roots and how it has progressed. The first “doctors” got paid for their house calls and so this has carried through. Americans want the best – the best costs money. Americans are so afraid of death and extraordinary amounts of money are spent to prolong life as long as possible. Somehow Americans believe they should not have to suffer because this is America – the best country in the world. This perception and attitude is our downfall. Health care in America will never change unless we all – patients and providers alike – step down our expectations and begin to accept reality. We need to look at the rest of the world – life goes on very well with a little less – and many people are a whole lot more content. If we don’t humble ourselves a little – God will do it for us and it won’t be very nice.
I’m seeing sanity here. Plain and simple.
But unfortunately EMTALA breeds the delusion that health care is free for all, any time, anywhere.
I don’t hate them or despise them. Jesus said ‘In as much as you have done it unto the least of these, you have done it unto me.’
It’s funny, ’cause I’m not at all a Christian. But I find this the most compelling argument to continue taking care of the uninsured. (Timely: I just wrote a long post about EMTALA.)
I agree that we should get paid for the work we do. As a practice administrator, my view is that we do: I charge $110/RVU to a UnitedHealth patient and $20/RVU to a medicaid patient. I do get paid, but through cost-shifting. This still strikes me as fundamentally unfair, since the commercial patients are obligated to subsidize the others. I would rather have a flatter fee schedule but have everybody be able to pay. Given that there will always be some people to indigent or improvident to be able to pay, my preferred solution is to have a compulsory universal health insurance program, funded by premiums from those who are insured.
Of course, in such a system, there will still be cost shifting, but it will be from a much larger population base to a much smaller one, so the individual burden carried by those who have to pay would be mush smaller than it is now.
I think a lot of the problems that Americans have in regards to medicine is plain old ignorance.
When I say ignorance, I mean the noun defined as “the lack of knowledge or education”. Most people have absolutely no clue when it comes to even basic medical knowledge. People do not even know how to define a medical emergency.
“My kid swallowed a nickel, is this Emergency Department worthy?”
“I have chest pain, is it gas or am I going to die?”
“Why can’t I see my regular doctor for two weeks? What if I show up and they tell me I should have gone to the ED? Won’t I be embarrassed.”
It has been my experience that the least significant complaints given have always been taken the most serious. I am a former EMT and even *I* do not know when to be seen immediately. Inversely the more truly immediate the concern, the more I *avoid* seeing a doctor.
Also, when I pull into a gas station I know what I am spending. While uninsured I was more likely to go out of country for a procedure than stay locally. Why? Because a Panama hospital will quote me a firm price. Why do cosmetic surgeons get more 100% paying customers? Does it mean that they only see people that can afford their procedure? I don’t think so. “Financing available” is a common theme. Almost everyone I know has financed all or part of their cosmetic surgeries. A lack of tranparency breeds contempt, in my humble opinion.
Whitecoat has a great post about it: http://whitecoatrants.wordpress.com/2007/12/11/the-high-cost-of-medical-care/ citing $129 boxes of Kleenex and $90 for a 70 cent lineset.
Well you see the thing is, you can live without gas. You may not like it, but you can. If you seriously do not have money for a lawyer, one WILL be provided for you. IN the town I live in there are several churches and organizations that feed the hungry 3 times a day, every day. Free food is available. It may not be what you would like to eat but it is there for the asking. See you cant live without food. Around here no one with any money at all will stand in line for a free meal…. so they do go to those who need it. A house? Nice for you that you have a mortgage to pay. Many dont. You will not die if you dont own a home. You can rent, of course that requires money also but if you dont have rent, well then, there are shelters ( sometimes) cars, tents, etc etc…… You could die without shelter, but you wont die from not owning a house. The thing is….. without heath care available people with little or no money will die. I understand doctors went to school for years and that they work hard and deserve to be compensated well. I dont believe anyone has ever said you should not get paid. What people are saying is there needs to be some kind of major change.
Raine,
If you need a lawyer, one may be appointed, if your problem is criminal, not civil. if there is some form of legal aid clinic, you might qualify for at least some evaluation and advice depending on the issue and your financial. Food? If you get some from a local charity pantry, that is only your good fortune; nowhere is that considered an entitlement. Medical care is different here. Unlike the legal aid clinic, where help is voluntary or the food pantry, where the same voluntary principle exists, under EMTALA, service is taken, not given voluntarily. Service is ripped from the provider at the convenience of the “consumer” who has, by force of federal law and hospital staff bylaws no power to refuse, even if the problem does not merit emergency evaluation or intervention.
Do we wake up the grocer at night, force him to open his store and hand out food without payment at whatever hour the caller wants? Do we do the same to the lawyer? No.
If we want this privilege, the notion of justice cannot end conveniently at the door of the private doctor’s practice. If the government compels me to give away my work to someone with no means to pay me, and I get no say in the matter, then the same government has the obligation to pay me fair market value for my service, nothing less. Any other arrangement is theft, with the policeman being told to look the other way.
I never said they should force you give away your work. I said exactly the opposite. What I did say was that something has to be available some how some way. A solution must be found.
Doctors need to be paid and people need medical care.
Raine,
That is exactly the answer I always get when I say basic medical care should be a fundamental (right/entitlement/whatever, there is even disagreement as to what word to use, and many people think medical care should be afforded only as a privilege).
Most doctors assume you mean the only solution to the crisis should be for them to donate their time, that you’re advocating theft, and no other services are provided for free, yada yada.
For highly intelligent people, some of these doctors lack imagination and problem-solving skills as the most basic level. All they see is that you’re proposing to force them to work for free. Obviously, that is not the solution, and I’ve never heard anyone even hint that it should be.
Nevertheless, you’ve just gotten the most common response to the issue on the blogosphere.
I think you all raise good points. I agree that people need health-care. But sometimes we miss a fundamental reality. That reality, for those of us in emergency care, is EMTALA. That law requires that we see everyone regardless of ability to pay. I’ve commented before that it was, in its inception, a good idea. It kept people from being ignored or transferred inappropriately based on financial situation. But now, it is simply a huge unfunded mandate.
The federal government knows what it is, knows what it does, and makes no effort to fund (or restrain) EMTALA. So we in the specialty, and consultants affected by that law, are probably sensitive to the idea of government intrustion in care, because government intrustion has resulted in our doing work mandated by law, but for free.
As scientists, to the extent that we are scientists, we see an example and extrapolate. If the government will do this to us now, why won’t they do it more in the future? You have to excuse us if we seem sensitive, but anyone in any field would be. No other field has this arrangement. If a lawyer is provided for you, that lawyer is paid for their work by the state.
I don’t want to ever turn anyone away who needs care. I don’t think I ever have. But fair is fair. It’s fine to theorize about the right, and we should all put our heads together and find a reasonable, equitable, just solution. But if you’ve never been compelled to work for free, under pentalty of law, it’s probably hard to relate to what we’re saying here.
Thanks for all of your comments, and for the passion and compassion you show for America’s vulnerable citizens. On both sides of the debate!
Edwin
It’s really not so hard to understand where you’re coming from. If you’re currently being asked to provide, say $100 worth of service for which you’re only paid $7, and your malpractice coverage, overhead and supplies are something like $50 for that service, it’s not difficult to see that you end up paying $43 out of pocket to treat that patient,and make no income, which you then have to figure out a way to make up somewhere else. It sucks.
The system is broken. We all agree the system is broken. But we’re stuck in the never-ending, ever-revolving argument of who deserves what and who should pay for what, and no one ever seems to suggest any solutions. It’s all griping on both sides of the argument, from doctors and patients alike.
Instead, let’s try to brainstorm some ideas that might ameliorate the problem.
Cleveland Clinic (or University of Cleveland, I’m not entirely sure where this originated), for example, has talked about free tuition for medical students.
What if other institutions followed? What if the federal government, which is currently wiping out our supply of primary care physicians, forgives medical school tuition for doctors willing to work in primary care for 4 or 5 years after residency (the doctor can still earn a living during this time)?
If enough people can reach enough of a consensus on how to begin to improve the system, then we can band together to put pressure on Congressmen, get professional organizations (the AMA and your state medical associations, etc.) to lobby for change, make a grassroots effort.
It may be a naive idea, but it beats the hell out of bitching and not problem-solving.
Anyone else?
Only 5% of med school grads the last 2 years went into primary care. Today over 1/3 of Americans do not have access to a primary care physician… not because of an inability to pay or other health care coverate… its because there aren’t enough primary care physicians. So… just having health care coverage does not equal access. Ask the folks in MA who now have coverage but only place to spend it is at the ED… and MA can’t figure out why its program cost more than they thought it would.
Forgiving med school costs for 3rd or 4th year med students who commit to primary care is a great start. Who will pick up the tab… GME? Might be a better use of GME than funding a residency program of plastic surgeons in excess of the Medicare patient capacity requirement.
Even if med school is forgiven for primary care physicians that would not excuse programs where Medicaid patients especially are getting service at 50% less than what the standard rate for service is.
So the solution has to be two-fold. Eliminate the med school debt that drives med students into the specialist arena which results in fewer PCPs. Also… the price is the price. The government is stealing service from the providers and privately insured patients are paying for it in not only their insurance premiums but also in the cost of the service to them which was “cost shifted”.
I read from you all that the system is broken, and I think that you may know what you are talking about. But today I was sent a message from the American Heart Association asking me to sign a petition encourageing law makers to listen to their plan to fix the problems. My problem was that their solution was not explained to me. I was supposed to blindly endorse their solution. When I dug around enough and found their talking points, it was only a lot of ideas on what health care should look like and no meat and potatoes on how to accomplish their ideas. Other than disbanding EMALTA that is mostly what I see from everyone. But then there is no real attempt to come together and decide on a platform that may be viable and still not leave the working poor totally lacking basic health coverage. Everyone seems to agree that they should be covered, but how to accomplish it is rarely addressed. And when it is addressed, it is mainly talked about as primary care. My employer provided insurance paid $125,000 to treat my cancer, and my cancer wasn’t rare. Do you really want to look some woman with breast cancer in the eye and tell her that she has to come up with $3500 every three weeks for her chemotherapy treatments while her illness is making her too sick to work? In the same line, I turned down a new treatment that may extend my remission because it could cost up to another $500,000 and only buy me an average of ten months. There has to be a balance to be able to ever have a workable solution. But there also needs to be more than a lot of people on all sides throwing stones at the glass house we all have. Does anyone have any workable ideas?
“Money and fuel/transportation? Neanderthal.
Money and homes? Shocking.
Money and food? Gastly.
We need justice, but justice may require payment? Inconceivable!”
I’m pretty sure that the USA, like every other developed, first-world democracy – certainly the one I grew up in (the UK) – offers the last three of the four examples you give to any citizen who needs them but cannot afford them.
Food stamps, housing and legal representation are available to Americans who cannot afford them. This would be the social contract. I personally grew up in a town council owned house, and had a school lunch paid for by the county. I now make six figures, and happily pay my taxes knowing some of it is going to help a younger me somewhere.
No-one’s arguing that the “free” (which of course, it isn’t, it is merely perceived to be free of cost at the point of consumption) services are less awesome than the really expensive versions. Welcome to capitalism. Nonetheless, as an American taxpayer, I’m already funding food stamps, low cost housing, and court-appointed legal counsel. Not to mention welfare transportation initiatives. And happy to do so. I’d prefer to subsidise universally accessible health care than EMTALA, but I’ll take what I can get.
As an Emergency Physician whenever I hear other EP’s bash EMTALA for making us provide a lot of free care it scares me. EMTALA costs us money, but it also saves our professional behinds. Yes I wish it was actually funded with more than the expectation that wealthy and/or insured patients will subsidize the care of others. Everyone agrees that EMTALA alone is short-sighted and is not sustainable.
This is especially true when so many people without insurance, or any intention to ever pay, choose to visit the ED because they want another narcotic Rx, some attention from their loved ones, or to get away from their loved ones. These are the patients we all find so frustrating. EMTALA makes me donate my time and expertise to those people, and I would prefer not to. ED abusers are the only patients that cause me angst in terms of EMTALA. I wish there was a way to divert them to a setting more appropriate for their needs, which of course is not allowed under EMTALA.
On the other hand EMTALA allows me to care for poor people who really need my help. The hospital will ever come down on me for wasting resources on people who can not pay. If any hospital or administrator asked me to modify my ordering habits when attending to poor people they know the fines, penalties and lawsuits would shut them down. Without EMTALA I truly wonder if hospitals would be so generous and how I would be able to care for poor people with serious conditions.
When I consider the most extreme of possibilities, I imagine being the lone doctor in an ED when a heart attack patient walks in. I imagine not being allowed to order tests or administer treatments because the hospital doesn’t want to lose money on non-payers. I imagine being asked to send the patient out, or call him a cab and wish him luck. I then imagine what it would be like if no cardiologist would take the hand-off because without EMTALA no one is obligated to care for any particular patient.
What would any of us do? We would be forced to just stand by and watch people die in front of our eyes knowing they might be saved if we could just get the right tests, treatments, and consultants. The fact that this does not happen when I work is worth the free services I am now obligated to provide. I can still afford a nice life with a good schedule, and I can actually sleep at night. I am not haunted by the dozens of poor patients I’ve cared for with brain bleeds, heart attacks, acute appendicitis, or other treatable, but otherwise lethal, diseases.
I’ve tried to make it pretty clear that I don’t want to turn anyone away when they need care. But there are groups, that you alluded to, who intentionally abuse our care, and who take up our time (and hospital resources) who could not only be treated elsewhere, but who also could be treated…well…nowhere!
I agree on a level. EMTALA is protective. It shields us, allowing us to do the right thing even as it forces us. Truth be told, it doesn’t exactly force us. Many of the things we see could be discharged after ‘medical screening exam.’ Toothaches, colds, sprains, etc. But we generally see them anyway, because we feel a moral duty to care for our patients, and because we often realize that there will be nowhere else for them to go.
But EMTALA is financially, ethically wrong as it concerns those compelled to give their care. The federal government should have funded it. We may debate whether there is a ‘health-care right.’ But if there is, in any way, there is also a responsibility of the government to pay for the right to care they are enforcing. And, there is a responsibility of those receiving the right not to abuse it, and to do their best to care for their own bodies as well.
Again, I submit, in what other ‘necessary’ industry does this condition exist?
Edwin
In no way did I mean to imply that you, or any other conscientous doctor, wishes to turn away patients in need. In fact I meant quite the opposite, because EMTALA laws also affect our colleagues and hospitals. Hospitals that might limit our ability to practice on these needy patients without EMTALA are non-existent, but I can envision a different and disturbing scenario.
I am also less outraged by EMTALA laws and their funding issues because i know that we as doctors, or more precisely our physician elders, spent over a century doing everything possible to protect physician territory and compensation, even at the expense of the common good, patient health, and a functional system. I believe that this attitude was as responsible for our current predicament as much as politicians bank rolling our mandates. In the 1960’s AMA and government antagonism and inability to work together created the Medi-care laws and practices that do not work for us. After decades of push back and posturing from doctors the population and government felt such a strong need to draw a lines in the sand that they were able to push these things through, regardless of funding.
Even decades before that, doctors were up in arms when workers and unions tried to work with doctors to figure out how everyone could have their health care needs addressed, and were willing to negotiate reasonable payment for those needs. If we as physicians had been more proactive and visionary we could have created the fair and logical system of our dreams in the 1950’s and 60’s. Doctors of the time were just happy to scoop up as much money as they could, and the government quadrupled most physician payments just to keep medicare afloat and avoid massive physician boycotts. Now that medicare is a fact of life, and the muscle behind EMTALA, the current generation of docs is paying the price. It is hard for me to completely lay all blame on the government, when physicians played our part in this debacle as well.