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There’s lots of discussion among politicians and “experts” on TV about the uninsured. The number is growing, and the push among some is to make sure there is “universal” coverage (which I assume covers people in the Horsehead Nebula and Andromeda Galaxy). The idea that some people would have no coverage for health problems frankly baffles people from other countries. How could we as a “civilized” country allow people to be without coverage?
I’m not going there. The social responsibility crowd can fight it out with the social darwinists. I’ll wait for the fight to be on Pay-Per-View as the Mega-Healthcare Social Responsibility Smack-Down. It’s probably the sanest way to solve the problem.
No, for me the issue of the uninsured is very different. We talked about it this morning in our office management meeting. How do we deal with the ever increasing number of people coming in without insurance? The issue is very complex and really gives us physicians significant inner conflict.
On one side, we are wanting to do whatever we can for the health of these people. Many of them have been our patients for a long time, and we have taken care of many generations, neighbors, friends, and coworkers. Some have been huge advocates, sending anyone who asks to our office. As a physician, I don’t really care if I make lots of money off of these people. In truth, because we don’t have to deal with insurance billing, they actually cost us less than insured patients. If I could, I would just charge them enough to remind them they are getting a service from me that does take my time, training, and skill to give.
But it’s not that simple. Even if I do discount my uninsured to minimal levels, the real problem for me comes when they need labs done, tests run, visits to consultants, or hospitalization. My charge is nothing compared to the amount they can accrue in these other venues. This ties my hands as to what I can do for them. They don’t get the care they need because it is too expensive.
One such patient that visited our office recently had a catastrophic eye problem that needed immediate attention. If immediate help was not given, blindness was likely. Despite strong warnings of risk and a direct call to ophthalmology, the patient refused to get the care required to save their vision. Most cases aren’t this extreme, but the likelihood of us running labs or referring for consults is much lower in the uninsured.
Another problem that happens is that money gets between us and our patients. We see them, do what we can to discount their bill, and try to collect a payment. Some don’t have full payment on them at the time of the visit, while others can barely afford it at all. We bill them the balance; some pay in full, but most pay either in part or not at all. The next time they come to the office we not only have to charge them for the care they are getting today, but also for past charges.
This is when one of my billing staff comes to me with the “what do you want to do?” question regarding them. Most of these are people I know. I don’t think of them as customers, I think of their kids and parents. I think about the medical struggles they have faced or the tragedies they have endured. I like my patients. Playing “hardball” is not that easy when you have an emotional attachment to your “customer.”
The issue of the uninsured will be on the lips of many pundits. Some will say “they pay for Cable TV, so why can’t they pay for medical care?” In some ways, they are right. I have worked hard for my degree and work very hard every day for my patients. I do deserve to be paid. But my job is to take care of people. I want them to view me as a person, not a commodity. The Hippocratic oath says “first, do no harm.” Not doing harm is getting harder and harder these days.
It probably would be less complicated if they were from Andromeda.
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{ 15 comments }
I have been one of those *uninsured by choice* when coverage wasn’t offered by my employer, and COBRA wasn’t available to me. It was a very tense time, when I had to pray for stable health & hope I didn’t have to ask for free care. I didn’t hesitate to ask for sample meds, I paid cash for the office call, I used phone calls to the office liberally, and I made it through.
I think there are many more like me, temporarily unable to afford insurance, than those who can afford insurance & play the odds that they’ll not need medical care. And I am always grateful for doctors like you, who try their best to help without much expectation of reimbursement. My family practice doctor seems to have the same philosophy as you, and you both are much appreciated for your efforts. Thank you from all of us you have helped, here & on Andromeda.
Its an ever increasing dilemma and you are on the frontline. Health-care reform is necessary and whether most would like to believe, inevitable. It seems that our country has many of it priorities backwards. Our government gives it citizens certain inalienable “rights” but, denies the necessities. We have the right to proper representation in a legal hearing and the right to an education but, are denied the right to proper medical care. We have the freedom of speech but, there comes a point in time when we must realize speech can only carry us so far and the things we profess with our lips we must put into action.
I’ve enjoyed your blog for a long time, and this post resonates with me. I went 10 years without health insurance, and I made it through by supplementing what grindcm said with utilizing free and low-income clinics. I was young and poor, in college, and without telephone and cable, but also – except for a couple of broken ankles and a bout with scarlet fever, without ongoing or serious illnesses.
Even with health insurance, though, no one is guaranteed care. My husband and I are both insured through our employers. I have traditional health care. He has an HSA. After four years of saving and paying the premiums, he developed TTP, experienced multiple organ failure and slipped into a coma.
He survived (and miraculously has only minor neurological side effects). But although he has an HSA; despite the fact that we long ago crossed the $2,000 mark; regardless of the fact that we have zeroed out the bills from all but two of the many, many providers who cared for my husband during and after his month-long stay at the hospital; and although the hospital gave the insurance company a $177,000 discount on their services; as of today (no foolin’) we are liable for the remaining balance that the insurance company insists is not their responsibility: $75,000, more than we make a year with our combined income. And, of course, he’s now been declared uninsurable.
Even among the insured, medical bills account for the majority of all bankruptcies. I feel for doctors and medical service providers. A good friend is a urology resident, and he sees a long battle ahead. But I feel for the rest of us, too. I don’t know what the solution is, but I’m leaning toward nationwide (let the aliens fend for themselves) coverage for one reason: the two great equalizers in a stable nation are education and medical care. We already provide the first, but lag far behind on the latter.
I hope this adds something to the discourse. I’d love to hear responses on my comment!
{Stacey & her Hubby} – This is exactly what is wrong with the North American private insurance system. I don’t claim any other system is perfect either, but I’d sooner pay too much tax than risk being declared insurable in a system I couldn’t afford to pay under.
Great post, Dr. Rob. A bigger and bigger issue. Working for a health center, I don’t have your bill collection issues as our care to the uninsured is subsidized. Even nicer, I can get most labs for most uninsured patients to fall under their copay as well.
But specialty care is a huge issue. If I get an unstable angina picture, about half of my patients say, “I’ll just have to take my chances.” And it’s all too frequent that we have patients die who likely wouldn’t have with appropriate specialty care.
Whatever “universal”ish system we end up with will surely be rife with problems, and indeed be great blog fodder for years to come on what some non-medical fool thought was a good idea. But if I can get a guy who is having a heart attack to actually go to the hospital to get care, instead of going home b/c he doesn’t want to put his family into bankruptcy, that will be a good thing.
Smak
Stacy, I am sorry for all you have been through, but medical bills alone causing a large number of bankruptciesis a fallacy that has been repeated ad nauseum. I am not saying that it is NEVER true, but that it rarely is. The study that started this story was proved biased and poorly constructed. There is usually much more of a backstory…
And grindcm, the “right” to healthcare is at the center of this debate. I propose that housing, food, and transportation are also “rights”, but that none of these so-called rights require others to provide them gratis. Public education is not a right either, but a social contract.
Hey Dr. Rob -
Not sure if you have time to read all your comments and this one is not totally related to this post, however it is a good post.
Have you seen or thought about commenting on the recent publication of the idea that family medicine and internal medicine should be combined?
I found out about the idea under the physcian discussion topics of March on emedicine.com.
Since I enjoy reading your blog and will be practicing medicine soon (4th year student in Atlanta GA) in either family or med-peds, I thought I might ask you what you think.
Kind Regards – IZ
p.s yes the pollen is heavy here too these days.
Pattie, RN I do not believe that I stated anywhere in my post that the right to healthcare was not at the center of this debate. Maybe we have conflicting ideas of what a “right” is to be considered. A “right” is part of the supposed Social Contract, whether hypothetical or consented and I believe your only stating the broader umbrella of which public education happens to fall under, along with the many other “rights”. By being an American citizen, I believe, you become a part of that social contract.
Hello just read your post through a link because I find it interesting how your (North American ) health system works as opposed to our Tax Payer funded free hospital system in Australia. We do have private hospitals as well, but its optional to insure and most people don’t like the gap payment in private, especially when you get similar service and same Doctors for “free”…..
The hospital system here I believe has the up side and down side of being tax payer funded. Firstly, socially, it’s a great leveler as the person who is financially disadvantaged can get access to the same treatment as the upper middle class Aussie who could probably afford private health. … (but won’t insure as I mentioned above).
On the down side, chronic health abusers and patients who make no attempt to manage their ongoing issues continue to wrought the system by becoming repeat admissions just on the basis of lazy neglect. And take for granted the ‘free’ medical care and in fact become critical and blas’e in the system.
BUT…. in these economic times when your average family is put under financial stress the fact they don’t have to worry about insurance is one less drama to contend with… that all of us taxpayers put in the kitty to keep the hospitals running is a godsend.
I feel sorry for those in environments where hospital and health care is not possible, easy or available.. and warts and all … I like our system. (Okay this is from a Nurse’s perspective).. I’m not sure about our Docs… ! But it’s food for thought -
cheers
1. why not pricing transparency? (i.e. why don’t patients know how much their care costs?)
2. why not competition for these tests? they’re extraordinarily simple to execute, by and large, and an actual market should reduce the costs. i mean, how hard is it to run a strep culture?
just some thoughts.
I, and I suspect most others also, am happy to see providers compensated for their services. I have no problem paying the garage to fix my car, and I think any skilled professional should be paid for the work they do.
That said, my car doesn’t cost $1,000,000 to fix. And I don’t run the risk of impoverishing my family, losing my savings and house, and saddling myself and my wife with debt for the rest of our lives, just to fix my car.
The mechanic works hard and is paid pretty well. However, I don’t see the garage’s owner living in a $10M mansion, flying on a private jet, and lobbying Congress to change laws to benefit his garage business.
What I do see is the University Hospital here going on a building spree, erecting multiple lavish “clinics” of 10-12 storeys, covering full city blocks, complete with lavish decor and, I’m sure, fabulous executive office suites.
Take PROFIT out of the system and see what happens…
1. why not pricing transparency?
Good luck with that. I recently went on peritoneal dialysis. The center affiliated with my nephrologist is not “in network”, so my insurance will only cover part of the costs. I have been trying for over a month to find out what those costs will be. I haven’t even been able to find a person who pretends they’ll give me an answer. Even the people at the local office can’t get a contact out of corporate.
I’ve followed the bills that have been submitted and covered by insurance. The difference between what an insurance company pays and what an uninsured individual gets charged is often several hundred percent, so I’m expecting to take a major hit. I’d just like to be given some kind of clue how much it will be.
Wait, why is it that you don’t “want to go” to the subject of guaranteed health care for all Americans? Working Americans already pay 2.9% of their income for health insurance that they don’t get to use (medicare) and the average family with private insurance pays another $12,700 for it. All working Americans are *already* paying for medical care. So why can’t they have it?
Joel: I can only post prices if I don’t file Medicare or Medicaid. The rules that surround Medicare and Medicaid are ludicrous.
Grondo: I am disgusted when I see the houses some docs live in. The docs you are talking about, however, are in the minority. Primary care docs are quitting because many can’t even make $100K/year. This may sound greedy to some, but with 7-8 years of training after college and an average of over $100K in debt, it’s not worth the long hours.
XYZZY: We charge what our best payor will pay us and then write off the difference for those who pay us less. This, however, means that the uninsured will be overcharged. Can we discount them? Our contracts with the insurance contracts don’t allow us.
Mark: I agree that the current system is a total mess (see lots of other posts I have written), but what is the precedent to saying that the government does things more efficiently? I really don’t have faith that politicians are the answer to our problem.
Second try to add this comment. If it is a duplicate, blog owner please feel free to delete the duplicate
XYZZY: I too am on PD, although for now, my insurance through work is paying for my supplies. I haven’t the faintest idea how much my dialysis costs each month (given the supplies, transportation of same, and all the medical tests that must be run each month); no doubt I cannot afford it without the insurance cover.
However, I believe Medicare covers dialysis supplies for otherwise uninsured people. If you have private insurance (through work or personal), they only have to pay for 3 years, then Medicare will pick up the cost.
I have been told that Medicare will pick up my costs of dialysis if I should lose my job (and hence, the insurance that comes with it) before those 3 years are up, so I’m keeping my fingers crossed.
Do you know which company is going to deliver your supplies? Mine is Baxter – they have an arrangement with the Northwest Kidney Centers (Seattle). I believe there is at least one more company out there that is providing some competition to Baxter (don’t remember the name).
If you have just started, feel free to look at the first few entries in my blog (more or less, November 2007, when I started CAPD, through Feb-March 2008, when I finally got on the cycler). If you have any questions, or just want to talk about PD, you can contact me through the blog.
Good luck with your PD, Xyzzy!
- Radi
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