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

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