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.