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