Unfunded Mandates and 'Fair Pay.'

This is my column in today’s Atlanta Journal Constitution.

https://www.ajc.com/opinion/er-care-now-is-583584.html

Secretary of Labor Hilda Solis recently produced an interesting public service announcement. In it, she stated that every worker deserves to be paid fairly for his or her labor (whether the worker is documented or not), and offered both a website and telephone hot-line which workers could use to report unfair payment by employers. (Incidentally, here’s the link: www.dol.gov/wecanhelp.) In the video, she stated succinctly, ‘You work hard, and you deserve to be paid fairly.’

Those of us who practice medicine agree completely. So we might reasonably ask if this announcement also applies to physicians who are under-compensated for their work. This routinely happens when patients are covered by Medicare and Medicaid, or by large insurance companies like Blue Cross/Blue Shield, which routinely negotiate unfair physician fees using their collective weight in bargaining. (Even as their executives bring home tidy bonuses that are clearly padded by denials).

I have experienced under-payment; but the worst form of it occurs because of federal mandate. I practice emergency medicine, and all those who do so are covered by a federal statute called EMTALA, or the Emergency Medical Treatment and Active Labor Act. Basically, this law states that hospitals which accept Medicare, and physicians practicing in those hospitals, cannot insist on payment for services; they can only bill after the fact.

EMTALA, well-meaning and appropriate in its original intent, was the mother of all unfunded mandates and essentially allowed the mess of modern medicine to move forward for over 20 years since passage. In essence, it propped up our health-care system by providing a kind of nationalized medical care ‘safety net’ that cost the government nothing more than the price of lawyers to investigate violations of the law. It allowed legislators to feel good about helping the poor and ensuring social justice, but without experiencing any of the unintended consequences themselves, either professionally or economically. And believe me, it isn’t cheap.

That’s because under EMTALA, the average emergency physician carries about $140,000 in unpaid charges each year; other specialties also feel the pinch to lesser extents. In fact, thanks to this mandate, my group now collects about 24% of our billing.

Not all of this unpaid care is given to those who would die or lose limbs without it. After 17 years in practice, I can safely say that almost every physician wants to help the truly sick, the truly injured and the genuinely poor. Unfortunately, much of the cost of EMTALA is generated by those who use hospital emergency rooms to treat the consequences of violent lives, drug abuse and generational entitlement. The cost is also driven up by those who use the emergency department to obtain narcotics, work-excuses and to avoid paying for their own medical care (when many could). As a result of the economic burden, hospitals close, physicians stop taking call and care is progressivley less available.

So, Secretary Solis announcement is good news! I now have recourse to report my unfair treatment by both insureres and the federal government. And she needn’t worry about whether I am documented. I am well documented by various medical boards, licensing bodies and most of all, the IRS. And rest assured, I have always paid the IRS. (Whether the amount I paid them was ‘fair payment’ is a topic for another discussion.)

Back to reality. Does Secretary Solis mean that I can receive redress for my grievance by calling the Department of Labor? I doubt it. I suspect that the hotline and website are for those who work in lower-paying jobs. Or jobs where there’s no need to wonder, as millionaire author President Obama wistfully pondered, when one has made ‘enough’ money.

I suppose the Department of Labor is concerned principally with those who do unskilled work, low-cost labor. That certainly fits the over-all agenda of the administration, which is clearly hostile to industry and business. I also doubt that Secretary Solis is concerned with physicians who work for the benefit of citzens and by the mandate of government. What a pity. A recognition of the unique payment problems in medicine would go a long way toward courting favor for her boss among the medical community.

The truth is that executives, legislators, cabinet members and everyone else in government would do well to be careful about deciding what constitutes fair payment, whether the checks are written on Wall Street or Main Street. That is, unless they are willing to suspend the standard progressive assumption that only the poor can be cheated.