In real life the millionaire would gladly pay the hundred bucks for the dinner, but would be upset at the doctor’s five buck co-pay.

– to the doctor?
– to the patient?
– to the HMO?
– to the gov’t?

There’s the fable of the doctor who saves the life of a millionaire who is choking at a restaurant. The millionaire insists on paying the doctor for his service and asks him for a fee. The doctor replies, “I’ll take half of what you would have paid before I got here.”

But let us look at what brought it about. There is a hospital chain in California that is notorious for taking out of network emergency patients and charging absolutely outrageous prices. Owned/run by a doctor. If you practice in California you know who I am talking about.

It was well noted by our nations founding fathers as well as the philosophers of liberty upon which they based their statecraft, that the foundation of liberty is morality, and that only a moral, virtuous people with generosity of spirit and a sense of fairness and justice can remain free. That if they allow greed or other vices abuse the liberty, then they will lose it.

This is part of what is happening in medicine. Once upon a time, when we were a free self governing proffession, we arbitrated fee disputes among ourselves. Contrary to popular mythology, most medical society intervention in fee issues were to prohibit abusive or excessive fees. The government stopped all such activity, so now greed where greed is found rides unbridled, ultimately resulting in the loss of liberty for all.

Emergency services by their very nature cannot be negotiated at the time of need. Abuse of that fact begs regulation.

What I would personally rather see is a sort of self-regulation: Not allow anyone to charge more than a certain percentage–say 125%–of the fee that they voluntarily accept from the private third party payor that is their largest payor. So if I sign a contract with BCBS and I accept 1000 from them, I can’t charge the “cash” patient more than 1250. It is a limit that I in effect accepted and set. For those who want to charge just whatever the hell number rolls into their head, they need to stay out of emergency services and still to treating patients who can effectively consent.

It is all of this other crap, which they shouldn’t be involved with (health insurance should be for emergencies, not routine care just like car insurance should be for vehicular accidents, not a new paint job or an oil change) that has screwed up the very thing they should be focusing on.

Medicare and Medicaid should lead the way in slowing phasing out of outpatient care so that the free market, in all its glory, can re-enter the market. Prices would soon come down in this environment. Lack of pricing transparency and lack of attention to the user (the patient) comes from third-party intercession – a position massively entrenched by the government’s approach.

What is the surgeon to do with the acute appendicitis in the ER? Negotiate a price before the surgery? Your suggestion that patients research the cheapest hospital, etc, in case they need it, is quite impractical. When a patient thinks they have an emergency they go to the nearest hospital, not the cheapest.

Your point about generics is fine, and I always prescribe generics when appropriate, so you are preaching to the choir.

As far as our current system being a one way course to bankruptcy, I agree completely. I just do not think free market principles apply to almost all medical care (only significant exception: cosmetic procedures).

A family practitioner

Why is driving a car any different?

I agree with the utility service analogy. But it goes a step further. Unlike the electric bill, which if unpaid will result in the power being turned off, there is outrage if a patient behaves the same way and gets cut off from the hospital and their doctors. So the electric company is accorded considerably more respect, and is never expected to operate at a loss, either.