Friday, August 6, 2010
The uninsured
The following post appeared in March 2009 on Musings of a Distractible Mind.
Have we made any progress?
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.
Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.
Labels: disparities, health care cost, health insurance, practice management, Rob Lamberts
posted by Dr. Rob at
11:00 AM
Contact ACP Internist
Send comments to ACP Internist staff at acpinternist@acponline.org.
Previous Posts
- QD: News Every Day--CMS: One step forward, one ste...
- False positives can cause real negatives
- QD: News Every Day--Did internists see a big pay r...
- QD: News Every Day--Giving it up for obesity
- QD: News Every Day--IMGs, iPads and medical educat...
- Regulating salt
- QD: News Every Day--Belt-tightening inside the Bel...
- Career counselor? Thoughts on becoming a doctor
- Should doctors be paid to communicate with patient...
- QD: News Every Day--'Don't know much biology ... '...
Blog log
Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs,
MD
Albert Fuchs, MD, FACP, graduated from the
University of California, Los Angeles School of Medicine, where he
also did his internal medicine training. Certified by the American
Board of Internal Medicine, Dr. Fuchs spent three years as a
full-time faculty member at UCLA School of Medicine before opening
his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical
Student Member, is a first-year medical student at the OUWB School
of Medicine, charter class of 2015, in Rochester, Mich., from which
she which chronicles her journey through medical training from day
1 of medical school.
Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and
general internist in the Division of General Internal Medicine at
Johns Hopkins. His research interests include doctor-patient
communication, bioethics, and systematic reviews.
Controversies in Hospital
Infection Prevention
Run by three ACP
Fellows, this blog ponders vexing issues in infection prevention
and control, inside and outside the hospital. Daniel J Diekema, MD,
FACP, practices infectious diseases, clinical microbiology, and
hospital epidemiology in Iowa City, Iowa, splitting time between
seeing patients with infectious diseases, diagnosing infections in
the microbiology laboratory, and trying to prevent infections in
the hospital. Michael B. Edmond, MD, FACP, is a hospital
epidemiologist in Richmond, Va., with a focus on understanding why
infections occur in the hospital and ways to prevent these
infections, and sees patients in the inpatient and outpatient
settings. Eli N. Perencevich, MD, ACP Member, is an infectious
disease physician and epidemiologist in Iowa City, Iowa, who
studies methods to halt the spread of resistant bacteria in our
hospitals (including novel ways to get everyone to wash their
hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating
medicine and the health care system.
DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about
health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more
than a decade and is an Associate Professor of Medicine at an
academic medical center on the East Coast. His time is split
between teaching medical students and residents, and caring for
patients.
Everything
Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science,
medicine, health and healing in the 21st century.
FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the
Internal Medicine Residency and Assistant Dean of Scholarship &
Discovery at the Pritzker School of Medicine for the University of
Chicago. Her education and research focus is on resident duty
hours, patient handoffs, medical professionalism, and quality of
hospital care. She is also an academic hospitalist.
Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings
of medical practice and the complexities of hospital care,
illuminates the emotional and cognitive aspects of caregiving and
decision-making from the perspective of an active primary care
physician, and offers behind-the-scenes portraits of hospital
sanctums and the people who inhabit them.
Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the
University of North Carolina School of Medicine, and the Program
Director for the GI & Hepatology Fellowship Program. He
specializes in diseases of the esophagus, with a strong interest in
the diagnosis and treatment of patients who have
difficult-to-manage esophageal problems such as refractory GERD,
heartburn, and chest pain.
I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an
interest in basic and clinical science and education, with
interests in noninvasive monitoring and diagnostic testing using
novel bedside imaging modalities, diagnostic reasoning, medical
informatics, new medical education modalities, pre-code/code
management, palliative care, patient-physician communication,
quality improvement, and quantitative biomedical imaging.
Informatics
Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical
Informatics & Clinical Epidemiology, Oregon Health &
Science University, posts his thoughts on various topics related to
biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned
authority on nutrition, weight management, and the prevention of
chronic disease, and an internationally recognized leader in
integrative medicine and patient-centered care.
Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of
hematology and medical oncology. His blog is a joint publication
with Gregg Masters, MPH.
KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites
for influential health commentary.
MD
Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of
medical practice, including controversies in the doctor-patient
relationship, medical ethics and measuring medical quality. When
he's not writing, he's performing colonoscopies.
Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics
in medicine, health care news and culture. Her views on medicine
are informed by her past experiences in caring for patients, as a
researcher in cancer immunology, and as a patient who's had breast
cancer.
Mired in MedEd
Alexander M.
Djuricich, MD, FACP, is the Associate Dean for Continuing Medical
Education (CME), and a Program Director in Medicine-Pediatrics at
the Indiana University School of Medicine in Indianapolis, where he
blogs about medical education.
More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice
internist, returns with "volume 2" of his personal musings about
medicine, life, armadillos and Sasquatch at More Musings (of a
Distractible Kind).
Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a
small community hospital in Connecticut. His blog is a series of
musings on medicine, medical care, the health care system and
medical ethics, in no particular order.
Reflections of a Grady
Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being
a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka,
MD, ACP Member, is a board certified rheumatologist in St. Paul,
Minn. He was a chief resident in internal medicine with the
University of Minnesota and then completed his fellowship training
in rheumatology in June 2011 at the University of Minnesota
Department of Rheumatology. His interests include the use of
technology in medicine.
Technology in (Medical)
Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in
education, social media and networking, practice management and
evidence-based medicine tools, personal information and knowledge
management.
Peter A. Lipson,
MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and
teaching physician in Southeast Michigan. The blog, which has been
around in various forms since 2007, offers musings on the
intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice
Boughton, MD, FACP, practiced internal medicine for 20 years before
adopting a career in hospital and primary care medicine as a locum
tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD,
FACP, is an internal medicine physician who has avidly applied
computers to medicine since 1986, when he first wrote medically
oriented computer programs. He is in practice in Tacoma,
Washington.
Other blogs of note:
American Journal of
Medicine
Also known as the Green Journal, the American Journal of Medicine
publishes original clinical articles of interest to physicians in
internal medicine and its subspecialities, both in academia and
community-based practice.
Clinical
Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP
Member, associate program director at New York University Medical
Center's internal medicine residency program. Faculty, residents
and students contribute case studies, mystery quizzes, news,
commentary and more.
Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so
he can create an independent, clinician-reviewed space on the
Internet for physicians to report and comment on the medical news
of the day.
PLoS Blog
The Public Library of Science's open access materials include a
blog.
White Coat
Rants
One of the most popular anonymous blogs written by an emergency
room physician.
2 Comments:
Thoughtful article. The issues surrounding who's insured, who isn't, the extent of coverage, the affordability of coverage, and how it relates to patient care are indeed complicated.
I know a young couple who is expecting their second child. Soon after they learned they were pregnant, the mother-to-be learned she would be laid off and lose her insurance coverage and that of their 6-year-old before the end of the year. The father works for an employer who doesn't offer family coverage. Coverage for the expectant mother and the youngster is $900/month.
This young couple makes too much for the state's Medicaid program, but $900 is NOT affordable. It is more than they pay in rent.
While conservatives in Congress and the media criticize "Obamacare," few offer solutions for couples like this one.
AJM says it well. Hard choices are made every day. The fuss about cable TV is a smoke screen for the real problem. Health problems cost much more than cable. Cable is a small predictable monthly expense that can be canceled easily. Running up medical bills leads to ravenous bill collectors and financial ruin. Cable is a fun distraction. Medical problems are fearsome. People with little money tend to spend what they have when they get it because who knows if they'll ever have any more.
Dr.s can be nice, supportive and relieve discomfort, but generally medical treatments are uncomfortable. And maybe the problem will go away if one waits long enough...
I appreciate your distress Dr. Robb, and I do try to deal with health issues appropriately, and pay bills on time, but I have not always been a "pre-existing" condition, fighting insurance company, and trying to keep head above water and live to fight another day. I am now.
We were better off when few or no people had health insurance and we just paid cash or made arrangement to pay.
Post a Comment
Subscribe to Post Comments [Atom]
<< Home