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On money, medicine and anger

I just posted a column I had written about EMTALA.  For those not in emergency care, it’s a law called the Emergency Medical Treatment and Active Labor Act.  It exists, as the column says, to ensure that no one gets turned away because they can’t pay.  In a way, it’s a great law.  It keeps us from being greedy scumbags and sending folks out of our emergency rooms when they’re truly sick, but just don’t have the cash or insurance to pay.

On the other hand, it has opened hospitals and physicians up to enormous abuses, since many people know they can come for almost anything with no intention of paying their bill.

Now, I’ve written about this before.  In fact, a piece I wrote about this has been posted on Flea’s blog.  I was looking at comments and saw some anger, and indeed I’ve seen a lot of anger about columns on medicine and money.  Some from within medicine, as doctors express their frustration over falling incomes.  Some from patients, who think doctors are all rich fat-cats who are pillaging the public.

I wonder, why is everyone so angry?  It isn’t just the money.  First of all, doctors do make a good living.  The problem is, we tend to over-extend our money and always need more.  A lake house, a new BMW, private school for the kids, vacations and conferences at resorts.  Not everyone mind you, but especially subspecialists live life to the edge of their ‘financial envelope.’  No one wants to hear a lot of whining about incomes that fall from 600K to 450K.  That’s just the truth, no matter how skilled or dedicated the particular physician may be.  Their anger comes from somewhere else.  I have lots of opinions on that one.  Their anger comes from losing control of their practices.  And nowhere more than in emergency care.  WE all want control, in any business. But, imagine a computer sales person who had to do the sale, but couldn’t collect the fee and couldn’t turn anyone away for not paying.  Or an electrician forced to give service without a guarantee of payment; after all, don’t we have a right to electricity?  A contractor who built homes, but only 25% were paid for?  We have a right to homes, don’t we?   Of course, doctors are also angry from believing that medicine and money will make their lives rich and fulfilled; a lie that mankind has believed for millennia.
On the other hand, there’s this groundswell of anger among the public, because medicine just costs too much.  And it does!  In lots of ways, it’s too expensive.  Simple stitches shouldn’t cost $500.  They do because insured patients pick up lots of the lost payment from folks who can’t, or don’t pay.
The system is set up so that those who pay, cover their own bill and the bills of others.  Fair or not, it’s the way it works.  But it’s not unheard of.  It’s similar to the way the costs of shoplifting are passed on to other consumers in retail stores.  Someone is going to pay, because the store can’t absorb all of the cost of stolen items.  Not that I’m equating non-payment with theft; it’s just a finaincial analogy.  But there’s a parallel.  When someone says to me that they wanted to see their doctor, but owe them money, and the same person drinks alcohol every weekend and smokes two to four packs per day, has a camera phone and a fresh tattoo, it’s hard to believe they simply can’t pay a bill.  In that sense, the theft analogy may hold some water.
But in the end, two facts remain; health care is expensive, and someone has to pay or else the system will not survive.

Aren’t the doctors all rich rapists of the public good?  Probably a few.  But most of the ones I know didn’t come from money or medical families.  They worked, studied and went to school.  (My mom is a nurse, my dad a preacher.  I paid for my college with a scholarship, and my medical school with loans.)  Most doctors started practices, and gave up time with family or other interests.  They did what capitalism demands in order to succeed.  But they’re perceived as being cruel opportunists who are cheating everyone.
I’m curious, is the populace angry at Bill Gates or any other entrepeneur?  Are the masses furious at the success of Oprah Winfrey?  Somehow, it’s different.  Entertainment, computers and electronics, these fall into a different category of success.  They apparently constitute proper success; success at giving people what they want.  No one bats an eye at television shows about rappers or athletes and their elaborate homes, or extensive car collections.

But doctors!  Oh my!  One reader commented on my column on free care with a very annoyed letter to the editor, ranting about doctors and their six figure salaries.  But what about seven figure salaries of football players?  What about the six figure salaries of contractors, brokers, owners of car dealerships, plumbers, researchers or academics?  Are they inherently evil?

My friend, Dr. Carol Rivers, hit it on the head.  People are happy to pay for what they want, just not what they need.  It’s frustrating to have to pay a medical bill.  But it’s less frustrating to buy a new truck, get a new lap-top, go to a concert, buy a pay-per-view sporting event.  People in our society spend money like crazy on what they want.   It’s just that health care is not what they want.  They want health, like everyone, but a huge number of people consider paying a doctor or hospital bill unfair.

At 14 years in practice, I can make some predictions.  It isn’t going to stop.  Doctors will still be frustrated and so will patients.  In the end, we’ll have national health insurance.  The medical bills will come out up-front, in taxes, and won’t seem so painful.  Then, the entertainment money can come out of the rest, for fun, as desired.

The health care system won’t be the same.  It won’t be ‘like now, but free’.  It will probably offer less amenities, less consumer options.  But maybe the people will be happier.  I don’t know.

I do know that all of the anger makes me tired.  I’m not angry about money, really.  I was insulted to see one person comment that doctors ‘just don’t want to see poor people’.  How sad an assessment.  I’ve spent a lot of my life taking care of poor people, people I knew would never pay me, people who needed what I could offer.  I have spent entire evenings trying to get them sent to psychiatric facilities for their suicidal thoughts, or stabilizing their critically ill children. I don’t have any problem with the poor.  All I really have a problem with is the anger.

I wish patients weren’t angry about health-care.  But people do, on some level enjoy their anger; enjoy their indignation.

I guess, if leveling it at doctors makes them feel better, we’ve at least accomplished something therapeutic for them in the end.

So, that’s one furious tirade?  That will be $75 please!

Ed

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Edwin

18 Comments

Schrodingers Cat

2007-03-31 03:19:22 Reply

Some things need to be said, and you seem to say them well. From one ED doc to another, the anger and frustration is there and does seem to be taken out on the M.D., even though we have VERY little control of billing, cost control, or even what WE charge. This is one of the main reasons many of us went into ED medicine–to just take care of SICK patients and not worry with all the other aspects (billing, collections, etc.) But as of late, we seem to be taking care or more non-sick patients due to the free (percieved) care in the ED, and dealing more with the bean counters, than taking care or SICK people.

Keep up the good work.

911doc

2007-03-31 05:29:36 Reply

To quote PJ O’Rourke, “If you think health care is expensive now, wait until it’s free.” Great post doc.

Jake

2007-03-31 23:01:30 Reply

Wonderful, very thought provoking post. I agree with you 100%

But then I’m a veterinarian and people expect that my services should be gratis because “you love animals”. Then they get absolutely incensed and claim that I don’t actually love animals and “you’re just in it for the money” when I have the audacity to charge them for my services.
People see owning a pet as a god given right, not the luxury that it is. You wouldn’t believe how annoying it is to have someone pull into my parking lot driving a brand new SUV and then claim they can’t pay for their cat’s dental care because “you’re just too expensive”. Or the ones that come to me with a sick puppy that they’ve just purchased at the pet store for $1500 that they can’t afford to treat because they’ve just paid $1500 for the puppy.

Or maybe you can believe it. Sounds like you’ve been there yourself!

Peggy

2007-04-01 04:07:46 Reply

This is a very thoughtful post. I like it that you mention other professionals/businesspersons who no one expects to provide THEIR services at very low cost or even free! Keep talking about this…the message may begin to sink in! And you brought in the good point that we prefer to purchase ‘I wants’. Medical care often isn’t so much fun to buy.

It’s a valuable status symbol to have access to the best medical care in the country, because it’s very expensive (Maybe that, in part, is what the non-sick, non-payers are seeking at ERs — they’ve probably heard how expensive that is and it’s their’s whenever they want it).

What I think is, most people today live in soap-opera fantasies, lots of drama, anger, fear, pitifulness — kind of like the old silent movies in which there were set plots, set gestures, set facial expressions, sets of words, and in the background the resonant music. Perpetual adolescence. Growing up, taking responsibility for our actions or lack of, is hard to do. For all of us.

Val Jones, MD

2007-04-01 04:47:09 Reply

Great post! You might enjoy Dr. Reece’s recent analysis of physician salaries – see here: http://www.revolutionhealth.com/blogs/valjonesmd/are-physician-salarie-3049

You are right that there is a lot of anger towards physicians – it is the collateral damage of the broken physician-patient relationship. When third parties (insurers) got between us, and reimbursement dwindled with drastic cuts in Medicare/Medicaid, physicians had to make up the difference in volume. When you see 30 patients/day none of them feels as if they’ve had a valuable interaction with you. And the physician’s memory of each individual patient (and their psycho-social context) becomes dim. When we lose the sacred, personal, physician patient relationship – we lose the best of what compassionate individualized medical care has to offer. This is why patients believe that a government sponsored system can give them the same level of care that they current receive. I shudder at the idea of handing over medical decision making to a distant bureaucracy that only knows what’s right for a population, not for the individual. But if doctors continue to treat patients like a commodity, the patients are actually receiving nothing more than population-based care anyway. Quality care is personal, and the physician-patient relationship is a trusted bond that cannot be easily broken. We need to know our patients well so that we help them to make the best possible decisions for their personal situation. I believe that the IMP movement (see Gordon Moore’s work) – where PCPs use IT to drastically reduce overhead costs so they can afford to see fewer patients – is one of the best ways to improve healthcare quality.

As far as Emergency Medicine is concerned – we need to get the non-sick patients out of the ER and back to the PCPs. Easier said than done – but if the patients have a real relationship with their PCPs they’re less likely to substitute an ER doc inappropriately.

My 2 cents! :)

joeh

2007-04-01 18:23:58 Reply

In a consumer driven world where we are forced by illness to stop being consumers and become patients entering a doctor focused world it is frustrating. We have to visit in hours that require us to leave our work, go to a place often inconvenient, sit in a waiting room full of germ laden out of date magazines often for an hour or more, fill out endless paper forms and have these same questions asked all over again. We sit and watch a doc fumble through a paper chart right out of the 50′s hoping that what he finds is actually our information and is correct. The doc then seems to rush us through our visit, tell us quickly what we should do, give us a script we cannot read and later find out is not covered by our insurance, hand us a piece of paper we must transport up front with a lot of strange numbers and secret codes, and then exit having to some back and start over again in a couple of weeks. Then the same docs sit and moan about retail clinics opening in their area providing better convenience and cost. Wake up to the new century and the age of the consumer or continue to get ever increasing anger directed at arrogant despots who we are foreced to continue to deal with every time we are sick. by the way, being a sick consumer can also make you very grumpy. One last thought on this issue and that is you by healthcares very nature are tied to the assholes of the world, medical insurance companies. People are often judged by the people they chose to or are forced to hang around with.

family med doc

2007-04-01 20:57:55 Reply

No one likes being sick. Someone like joeh is exactly why I’m getting out of medicine asap. joeh’s response is seething with passive anger and resentment at doctors……

Farmdoc

2007-04-01 23:09:56 Reply

We have gotten into this mess by our on doing. We, as a profession, have had a minority of docs over the years, who have cheated, mistreated and generally fallen for every greedy temptation you can think of. The result, over the last 100 years (about the same time cocaine became popular), has been malpractice, substance abuse, crimes for financial gain (which includes going into medicine for the wrong reasons) and self-pride. The results have been arrests, divorce, increased stress, law suits, etc. The bad publicity has added to the negative light and diminishing respect for our profession. Insurance rates skyrocket due to the costs of all of the above, thus increasing stress, raising costs of doing business, tempting the public to file frivolous suits for potential millions, and so on………. And the circle of fun goes around again, and again.
Yes, I feel the stress. But my faith is grounded in something other than medicine. This doesn’t mean I do not care for medicine as a profession; quite the opposite. In fact, if given the opportunity to do it all over again, I would still want this job.
We can whine and get angry. We can be quiet, and do nothing, or we can get off of our assets and participate in the cure. The bitterness, depression and frustration are like a bad fungus on our faces. It may take more than a day or two to clear it up, but if you’re persistent with the treatment, it will get better.
I agree with the idea to follow the legislation in Calf. and initiate the same in your state. If you stir the pot, something will happen. I’m on your side, Dr. Leap.
See ya soon?

Ned

2007-04-02 16:54:51 Reply

Farmdoc, you’re definitely on the right track in your comment, but the problem is both larger and more general than than you describe.

In simplest terms, what is happening is that the social contract doctors operate under is coming unraveled. And unlike most other professions, the existence of this contract is essential to the practice of medicine. After all, one component of this contract, the Hippocratic Oath, dates back to 4BC or so. You don’t see comparable strictures in other professions, even the very oldest ones.

I don’t know for sure when this unraveling began, but it isn’t a recent thing and there are many underlying causes. One early example is when, at the turn of the previous century, the medical profession effectively turned a blind eye to the regulation and then criminalization of various narcotics. Regardless of whether or not regulation was a good thing, the near-complete abdication of regulatory responsibility to government control was, in hindsight, a terrible failure.

Another example is the one Farmdoc points out: The failure of the medical profession to adequately police its own. Almost all doctors, if they are honest with themselves, know of a case or cases where someone in their profession did something unconscionable that should have resulted in discipline or even expulsion, but which did not. This sort of thing breeds deep distrust in ways almost no other action (or inaction) can.

Another one: The whole situation with insurers and other third parties getting between doctors and effective delivery of medical service. Val Jones is quite right in observing that a doctor who sees 30 patients every day is unlikely to earn the respect of very many of them. Indeed, the profession is actually lucky that your average Joe doesn’t understand the importance of proper patient histories and physicals and therefore doesn’t appreciate how patient care is compromised by such practices.

But my personal “favorite” is the general failure of medicine to comprehensively evaluate its own performance and take corrective action where needed. Other professions have made enormous strides in understanding their own processes, how to measure them and deliver better and more reliable service. Yet medicine stubbornly refuses to do this overall. There are specific specialties, such as anesthesiology, which have made significant progress in this regard, but you’d think the profession as a whole is still operating in ways that stopped making sense at the end of the 19th century.

The net result is that people are angry and are probably going to get a lot angrier. And while it is convenient to blame the patients, the public, the lawyers, insurers, drug companies, or whoever, for the woes of modern medicine – and to be sure there’s blame aplenty for all of these – the solution has to come from medicine itself. My two fears are that the profession lacks the collective will to do this and that even if the will exists things have gone so far that corrective action is no longer possible.

batwimp

2007-04-02 17:03:21 Reply

I’m not a doctor, but I’ve been a patient many times (or the stand-by as my wife was the patient). Perhaps the answer to the problem is to make the patient pay with time if they don’t have money. If someone comes into the ED and gets treatment, then can’t pay, maybe they could come back when they are well, grab a mop, and clean up some of the rooms. Then maybe it will dawn on them what people look like when they are really sick. Maybe they will gain a better appreciation of the work that doctors do. Maybe a couple of hours of mopping up blood, urine, and other bodily fluids will flip a switch in their brains that maybe they weren’t really sick when they checked in, and have wasted valuable resources that will eventually be billed to someone who took the time to get some training somewhere and found a job that actually offered health care benefits.

And as for the above comment blasting doctors and the ED, maybe joeh should come to someone like me the next time they are sick. I’m a programmer. I can’t actually evaluate what’s medically wrong with you, but I can type the symptoms into a PHP form and let you look at it surrounded by beautiful cascading styles. It won’t help your illness, but you don’t like doctors anyway, right? Oh, by the way, I’ll still charge you $125 an hour for my services. And there’s no insurance out there that will cover it. Cheers.

Flea

2007-04-02 20:04:38 Reply

Thanks for the nod, Ed,

My problems with EMTALA, as you know, go way beyond the money issue. They have to do with our losing our sense of what it means to be sick and what it means to be healthy. It’s a long story…

best,

Flea

Apollo

2007-04-02 22:52:33 Reply

Thanks for the very thoughtful post and recounting Dr. Rivers’s characterization of patient anger in the context of what people are willing and not willing to pay for. Definitely a lot of things that young’uns like me need to keep in mind, going into the practice of medicine.

webhill

2007-04-04 17:51:50 Reply

I’m a veterinarian like one of the previous commenters, and I have to say I totally agree. People don’t want to pay health care bills for pets any more than they want to pay physician bills – and they expect vets to be in the business for love of animals and therefore not charge them. I vividly recall being reamed out in my waiting room by someone calling me an “evil greedy b*tch” because I had the temerity to charge $20 for dispensing some tranquilizers for a cat. I wasn’t the practice owner and it wasn’t up to me, but trust me, it was a complex situation and I was only billing for the drugs! The the owner drove off in a Lexus SUV. I was so mad.

Fabella

2007-04-04 23:31:58 Reply

About 8 years ago, my group stopped seeing Medicaid, after an audit revealed that the practice lost about $15 per Medicaid visit. The law states that Medicaid has to provide just enough funding to keep docs in the system and my group determined that it wasn’t enough.

The incredible public outcry could have been foreseen. Yet, other docs defended the practice with similar reasoning to yours.
Health is a basic necessity, but some people inherently are healthy.

EVERYONE needs to eat. Does Kroger/Albertsons/Piggly Wiggly provide food to all who show up for free? No. Do they provide it for 10 to 30 cents on the dollar? No. Supermarkets who take food stamps are reimbursed IN FULL.

Shelter. A basic necessity. Landlords who provide Section 8 housing are reimbursed IN FULL by the goverment. Not at 10-30% of what is billed.

And if the supermarket gives away $100,000 worth of food, they can write off the FULL $100,000. Few outside medicine know that doctors are in the ONLY profession that can not write off ANY of their free care/bad debt. Not one penny. Yet, every doctor I know provides care to people they know will never pay.

Do we make a lot. Yes. But we give a lot too.

ERnursey

2007-04-08 02:03:44 Reply

The cost of healthcare has done nothing but rise since EMTALA was enacted. Hospitals rape the insured in an effort to make up for all the free healthcare they have to give. Since we can’t turn anyone away there is a large contingent of patients who feel free to come to the ER with any bullshit perceived problem they think they have. And we are afraid to say no to them for fear of another government regulatory agency coming down on our facility. Baugh.

周易

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