Why must medical care be provided for free?

Our septic tank backed up recently. When I say backed up, I mean, into the basement. And when I say into the basement, I mean, out of the bathroom and onto the carpet. And under the walls. The stars were aligned, and I had to go to work. My wife borrowed a Shop-Vac and rented a steam cleaner. I was assigned to call the septic-tank guy. The kids helped clean up, and remain traumatized by revisiting their own body fluids … and solids.

Septic tank guy, who worked on our system a few years ago, said, “Oh, yeah, you’re that guy with all them children.” (This is the response I often get when people hear I have four, count ‘em, four children! The madness!) He informed me that we probably had overwhelmed our system and might need a new one. We were going on vacation, so it could sit until we returned.

Fast forward. The septic tank guy finally came, and found the problem after digging in our packed red clay with a backhoe. He was confident that I had never seen anything that disgusting. (I chuckled to myself. Real people can be far more disgusting than inanimate waste.)

The cost for locating and pumping the septic tank was $675. Hallelujah, no need for a new one! He came to the door, and handed me the bill. I told him thanks because he did a great job, and said I’d mail the check.

He paused, slightly flummoxed. “I can’t get paid now? Most people pay me right away. I mean, when can you pay me? I have to dump this, and it comes out of my pocket.”

I tried to explain that I could, indeed, write a check, but having just done my other bills, it would bounce. I’d need to move a little money around. “Well, I can work with you, but how long will it be?” asked my frustrated septic tank guy.

‘Look, I’ll send it to you tomorrow, but I just can’t hand it to you today. Do you understand?”

“Well, yeah, but I have expenses you know.”

At which point I launched into an explanation of how I see people all day who do not and likely will not ever pay me. I don’t think he bought it, but he went away, no doubt complaining that the doctor — the doctor of all people! — wouldn’t pay him when services were rendered. The horror!

This strikes at the crux of the problem facing physicians, whether working in EDs or on call for hospitals under EMTALA. Everyone (politicians, administrators, patients [AKA consumers], and customer advocates) is confident of a few things. First, emergency medical care is so important that no one should be expected to pay at the time of service or indeed ever “if they really need it.” “Emergency” means, in current parlance, everything from a painful tooth to sunburn, and of course, vastly worse things like lost prescriptions, heart attacks, trauma, and lack of confidence in a home pregnancy test.

Second, physicians are always wealthy, and have ready reserves to pay cash for everything. And third, nothing else is subjected to the immediacy of medical care. Let me interject here, a basement of sewage rises to a level of emergency far surpassing chronic back pain, poison ivy, possible insect bite, a prelitigation physical for whiplash, and other things that if listed would fill this publication.

Life is full of crises that are, believe it or not, nonmedical. If you are traveling with your children and your minivan gives up the ghost (Southern speak for dies) and you’re stuck in the middle of Iowa, you have a crisis. That crisis requires payment by credit card, insurance coverage, check, or cash.

If the roof blows off your house, you have a crisis. If your freezer or fridge stops working, if your electricity shuts off, if you have no water, you have a crisis. A house infested with fleas (and I speak from experience) is a crisis. These days, the way our economy and educational system uses Internet connectivity, having no Internet connection may even be a significant crisis.

Each and every one of these things, including food and water, requires payment unless you pack up the family, go off the grid, and set up your own compound. (I’ve considered it, believe me.)

So why must medical care be provided for free? Either via the cruel taskmaster of EMTALA or through universal health care? That is a reasonable question but one that no one in authority has the ability or honesty to address. Ethics, philosophy, and politics don’t mix.

More to the point, though, why is it that the government mandates that we provide care without immediate compensation but provides no voucher, no malpractice protection, no tax credit? This is a terrible double standard, and it needs to be brought to the desks of our legislators, county and state -medical societies, and national -organizations.

It creates an untenable economic situation, which partly explains the -closure of hospitals and EDs. This problem for practitioners lies behind the move of physicians from being owners to employees, the tendency of specialists to abandon on-call, and the desire of emergency physicians to leave clinical practice. Sometimes it’s burnout. Often these are explained by simple economics — and very reasonable frustration at the -asymmetry of the situation.

Medical practice and life is costly, but when the money doesn’t come in, it can’t go out. Anyone with a home, a family, and a practice will understand that this can’t continue. Herb Stein, Ben Stein’s economist father, said, “If -something cannot go on forever, it will stop.” The question is, what will America do when it suddenly has to pay for what has been free since 1986?

The plain truth is, as my septic tank friend said, “We have expenses.” At the end of the day, unlike our patients, we aren’t excused from paying.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

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  • John C. Key MD

    Amazing, isn’t it? This perception that “all physicians are rich”. Those I know who are rolling in money are working at least double an 8-hour day, and don’t have much time to roll in their dough. The only good solution is to return medicine to a cash-based business like that of the septic tank man, but I don’t see the will to do that anywhere. Physicians as a group seem more content to gripe, work for free, and leave the decisions to politicians and administrators.

  • NormRx

    The entitlement beliefs in this country are amazing. I own a duplex the tenants are on housing allowance. It varies throughout the year, but last month they payed $115.00 and H.A. paid $635.00.
    I received a letter from them describing their wish list. They wanted a fence separating them from their neighbors, they wanted new laminate flooring in the living room. and they had an ant problem. They moved in 6 years ago. I lowered the rent from $800 to $750 because they told me that was all they could afford. During the past 6 years I replaced the furnace, A/C unit and water heater. I also replaced the roof and had the deck repaired and stained. Total cost around $9,000.
    When I went to see them I told them I would take care of the ants, however there would be no fence or new laminate flooring and the rent would revert back to $800, which I was getting 6 years ago. The rental housing market has really firmed up in the past couple of years and I could easily get $875 for this unit.
    When I told them I was going to raise the rent to $800, the wife started hollering, crying and screaming (It brought back vivid memories of my marriage 25 years ago) When I told her that I am merely going back to the rent I was receiving 6 years ago, she didn’t care. She though when she moved in there would never be a rent increase. I could go on, but you get the picture.

    It amazes me that anyone would go into medicine. I truly sympathize with the many good physicians that are getting squeezed by insurance companies and the government. When people have their free health care, but no access to a physician maybe then they will be happy.

    • civisisus

      happily for you, the owner, you can terminate the lease. You aren’t obliged to rent to them. Oh, wait, what’s that? It’s economically worth it to you to do so, despite all your whining?

      Please shut up.

      Your fellow landlord,

      • NormRx

        You are probably a slumlord and use to dealing with self centered people that feel entitled to freebies. Or perhaps, more accurately, you are one of the leaches and not really a landlord.

    • Payne Hertz

      In most states under the “warrant of habitability” you are required to make necessary repairs to maintain the premises in habitable condition including replacing the flooring if necessary. The warrant of habitability is part of the lease agreement you signed with the tenants, so it is not like you were doing them a favor fixing the furnace or ac. If you are receiving money from Section 8 or other such programs you usually cannot just arbitrarily raise the rent but have to get the approval of the agency in question first. That is the price you pay for getting guaranteed rent payments every month through these government programs, without which you might not have a tenant or might get one who was a helluva lot more demanding for the money she pays. If you don’t like your tenants you are free to not renew their lease so long as you give them whatever advance notice is required in your state.

      People go into medicine for the same reason they become landlords: there is money in it, all BS aside.

      • NormRx

        I know landlord/tenant law. I have rented to both rent subsidized tenants and tenants that paid their own way. I have found that the rent subsidized tenants are the most demanding and this is the last one I will rent to. If you ask most physicians they will tell you the same thing, the people that are getting their services for free are the most demanding. The purpose of my post was to point out that the people that are the most demanding are the ones that are being subsidized by the taxpayer

  • Barbara Fisher

    I challenge you to compare your tax return to the Septic Guy. Yours is probably 4-5 times more income than his. Perhaps you should work for a salary that will still be 3-4 times the Septic Guy’s. You should have paid him when he was finished. No one feels sorry for you besides other whining physicians. You were a jerk.

    • http://www.facebook.com/people/Rita-Chobanian-Swisher/1125771124 Rita Chobanian Swisher

      Barbara, you have shown yourself to be quite petty and nasty. God forbid you should need a physician’s services someday.

  • southerndoc1

    You make some good points, but you should have made arrangements to be able to pay the septic tank man before he showed up at your house.

  • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

    I respect people who want to provide free healthcare or free anything to the needy when they are advocating it come from THEIR OWN time, energy and resources instead of from ANOTHER HUMAN BEING’s time, energy and resources. I don’t recall ever seeing that, because the people who do that are low-key, sincere and humble.

  • MN MD

    Surely you must see the difference between healthcare and repairs to your house or access to internet, right? The latter examples are luxuries that you are quite fortunate to have in the first place; no one needs either to survive in this world. But our health is integral to our basic self…without health and life, these material posessions are meaningless. Health is not something that should be reserved for only the wealthy, but for all citizens. It is a basic need that we, as a society, need to value.
    Admittedly, we work in a broken system where the ER now doubles as primary care, but this (for the most part) should not be used to illustrate a “sense of entitlement” among our patients or “how crappy it is being a doctor these days” but rather illustrates how little value our society places on the health and well-being of our citizenry. Rather than complain about how this system hurts providers, we need to recognize how it hurts our patients first. Think of how desperate a patient must feel to know that they cannot recieve care without bankrupting their family. Certainly, physicians should advocate for their ability to make a good living, but it is all moot if we are not accomplishing the goal of healing our fellow man.
    As a recently graduated medical student, I got the unique perspective of seeing all of the frustrating aspects of our broken system from the provider standpoint while still identifying with the patients who struggle financially and lack access to healthcare. My wife recently needed to be evaluated for a mass in her breast. Sadly, due to lack of reliable health insurance, much of our worry (and subsequent relief) centered around if/how we would be able to afford cancer treatment/surgery rather than on her simple survival and prognosis. Frankly, I would love the ability to be in your shoes: not having to worry about health coverage, and instead simply worrying about the septic tank in a house you are very fortunate to own.
    Hearing you complain about getting repairs to your home along with your arrogant exchange with the repair guy, then subsequently railing about the health needs of the patients you pretend to care about each day makes me, quite frankly, ashamed to be entering the same profession. Thankfully, my experience with many good young compassionate doctors, residents, and students helps me believe that our field will become filled more caring physicians who actually recognize the difference between house repairs and healthcare.

    • Bladerunner2010

      —ashamed to be entering the same profession.—–

      Talk about arrogance: You lecturing a physician with far more experience about the medical field.

      Let’s see if you’re singing the same tune in a few years.

      • MN MD

        Thanks for your thoughts! While I respect his years of experience, I wholeheartedly disagree with his ideas on healthcare policy and his choice to callously demean his own patients to justify his political point. He chose to post his opinions on a public medical blog and invited commentary on his thoughts, without the stipulation that respondents be doctors with more experience than him. Please see my response below to hellcat mary if you need further understanding on why I felt it appropriate to “lecture” this senior physician.

        • http://www.facebook.com/profile.php?id=662132748 Lata Potturi Schaedler

          There are so many physicians in my area who can barely collect a salary after paying their overhead and expenses. They see many patients for free. Several are living paycheck to paycheck after paying enormous student loan payments. The difference between the plumber and the doctor is the doctor is required to go through years of expensive schooling and underpaid training before being allowed to practice. Yet, the plumber can collect payment on the spot while the physician is expected to provide services and “hope” to get paid. Surely you see the reason this physician is complaining, don’t you?

          If you don’t now, I promise you will in 5 years.

    • Hellcat Mary

      Wow. An arrogant college graduate. Color me shocked.

      Look, your values are in the right place, but your head is in the clouds sweet heart.

      And guess what, I’m not a physician, or established in a firm career of any sort, or even well-off (or even kind of well-off). I’m not preaching to you from the green side of the fence here. I’m an aged 24, surfing by with a GED, average joe-schmoe girl in between average joe-schmoe jobs who would LOVE to be financially set one day but right now I’m pretty down in the dirt (and no I don’t have kids, don’t plan of having ‘em, and even if I did welfare can still suck my balls, I don’t want your pink-is-for-poor vouchers. I’d rather stand in line at the CVS with a pack of condoms than stand in line at the DFCS with a pack of kids. Hey, would you look at that, I’m taking initiative to insure my own well being already). I’m a little worried about utilities and a lot worried about rent, so don’t talk about what is or is not considered an emergency to us poor destitute dregs down here in the lower tax bracket; cuz if my butt gets evicted I’m hitting the pavement nose-first, and I won’t be thinking about doctors then: I’ll just have to slap a band aid on it and keep on truckin’.

      Yeah- I need some dental work, my glasses are hanging on by the durability and sheer magic of scotch tape, and it would be super swell to be able to afford a co-pay on the prescriptions I need for some chronic medical issues, because I had insurance and now I don’t. But I don’t have any illusions of having my hand held by my “fellow man” and being gifted these things. Frankly, I’m motivated to find a job, any job, that involves the words “Blue Cross Blue Shied”. Or, screw that, ‘Cigna’, because that was a cheaper co-pay, and I love me my generics. *Volunteering* ones’ time and medical expertise to those not in a position to pay is one thing (which does happen and is available if you’re motivated enough to type in a search that includes your zip code and doesn’t include the phrase ‘family and children services’ on The Google. Trust me, I know from experience.) Hell, charity is one thing, and I’m all for the idea of strengthening government and tax supported systems of healthcare that are already in place, but I don’t want to be strong-armed into providing my neighbors’ healthcare for them and their rugrats anymore than I expect my neighbor to do it for me (and he’s a doctor… well, maybe a nurse- he wears scrubs and drives a Dodge Challenger, is my point). Or, more to the point, open up their door and offer me their couch and a warm meal (because that’s what’s really on my mind right now, get it?) I agree, even, that the standards and practices of the health insurance market as it is needs some significant restructuring and overhaul. But these are different solutions altogether from ‘free healthcare’.

      Even through all this, even for all the complaining and demanding and posturing I should be doing as one the those ‘less fortunates’ (and thank god you understand us, that you want to help up rise above with your healing hands, where would we be without you?) I get that healthcare, like most other institutions that function on an exchange of currency for the provision of goods and/or services, is a business. Water, food, things that are also as “basic” to human needs and nature as people rail about healthcare being, often come with a price tag (not saying it’s awesome, I’m saying it’s capitalist). And here’s the crux of my problem with “free” or nationalized healthcare- not the entirety, just that single idea I circle back around to no matter how I may flux on other topics of the issue, depending on how charitable I’m feeling at the time of debate- and be prepared because here’s where all that self-entitled derision I should be feeling about not having the cobblestone fountain in the front walk of that Victorian mansion I haven’t earned yet comes into play.

      I’m a pretty strong believer in the old adage that beggars shouldn’t be choosers; and on the subject of community supported free clinical programs and government subsidized medical plans I can’t think of a more apropos statement to make on the thing. Furthermore, if I should ever find myself seriously ill (because hell, maybe I’m wrong and I don’t know it but karma does) and have cause to turn down one of those aforementioned avenues, then I will take any help I can get, if any, and be grateful for the physician that despite paying his dues and his loans and his residency and god awful hours of blood and puke and bed pans (oh, my) he (or she) is still offering to care for my ailments despite no assurance of monetary profit. Thank you, truly, for you are a far more generous soul than I. Or you just have a stronger stomach.

      However, as in this is where I interject that great big ol’ BUT, the important part here is that in this scenario- the one where I’m hacking up blood and my fingers are turning black- I am emphatically ‘the beggar’. Begging. Which indubitably means that I am not ‘the chooser’. And forgive me, even though I’m not really apologizing, but I don’t really fancy myself in attendance of that beggars banquet every time I have the sniffles, or the Ebola. As admirable as this strive for equality in the wellness and health of every American life is, unfortunately it’s just flagrantly unrealistic as well, and the problems far outweigh the benefits (granted: that’s probably depending on who you ask, but for the purposes of this argument you’re asking me, whether you meant to or not.) I’ll go one step more and put it even more plainly for you: Just like any other business you’re likely to have expectations of, it is a competition to keep the customer satisfied and coming back (a.k.a: paying you). A patient by any other name is still a customer. The privilege of healthcare in America is *not* the privilege of being “healthy”- it is the privilege of telling any service that you’re dissatisfied with to piss off and that you’ll be taking your business elsewhere. And please don’t let this hurt your feelings, but if you were my physician, right about now I’d be telling you to ‘piss off’.

      It’s not because you’re not a sweet guy, teddy bear, or because I think you don’t have good intentions- obviously you do. Don’t get me wrong, I’m glad you care, I am, but purist of heart sentiments are just as flawed as blatant greed in the professional practice of medicine, only it comes with an even more devouring sense of superiority and inflation of ego. The fact is, your doe-eyed, all is full of love, fresh off the conveyer belt views of how destitute and in need of saving those like myself are do not leave me feeling confident in your ability to be an effective doctor. They leave me feeling patronized.

      • MN MD

        Thanks for your succinct & coherent response! I appreciate your thoughts. Unfortunately, you have badly pigeon holed me for what I am not: some doe-eyed green student in his early 20s trying to save all of the “little people.” I am very much not that. I am a 33 year old who has struggled plenty in and outside the field of medicine. I chose to go back and invest in 2 years of undergrad classes just for the chance of having a shot at medical school, and eventually become the doctor I am today (not just a sniveling little college grad as you seem suggest). I have been plenty fortunate along the way but have also sacrificed much and worked my ass off to get to where I am. With that in mind, one could say the same thing about your lengthy reply as the previous responder did of mine: lack of respect for those with more experience. But that is, in my opinion, completely flawed logic. I have no idea who you are and what you’ve experienced and what would be TRULY arrogant is for me to tell you that you have no right to question me because of the extra decade I have on you.

        While I won’t question you simply based on your age or experience, I will not have you write me off likewise because of a stereotype you may have applied to me. This author’s essay and my response are mainly a discussion of how our society should approach healthcare. At the same time, however, the author has chosen to give us a glimpse into the callous nature with which he approaches his patients. It is this glimpse that prompted me to personally question the way conducts his practice.

        An ER doctor far more senior than myself or the author once gave me the advice to “remember who the patient is.” In short, what good is an angry/jaded doctor who constantly sees himself as the victim of some afront? Do I think we need to coddle and pity every person who comes through the door? Of course not. But I think it reasonable to expect doctors to treat their patients with respect, and to at least try to muster some compassion for even their most difficult/frustrating patient rather than use them as examples for a political point on their blog. You can call me arrogant if you like, I will always question a doc that fails in this basic goal and perpetuates the stereotype that doctors don’t care.

      • snurfy

        I was waiting for your head to spin around! If you ever do need this doc, I hope he tells you to “piss off”.

  • http://www.facebook.com/profile.php?id=100003366286858 Nurse Holt

    I recently went to the ER. I had vertigo which had never happened to me in my life and frankly I was worried. I felt terrible, like riding a roller coaster at times. I am very fortunate to have good health insurance. I checked in was treated and released. As I was clinging to my husband to get into my car, I was loudly and rudely told I must walk over to check out to pay for my service. Seriously? The last thing that I needed to be doing at that exact moment was trying to count out cash for a copay. Not only that, I doubt my bill hadn’t even been completely totaled yet. What if my bill was calculated on a co-insurance system? Would I have just had to pay a round about figure with no accuracy since contractual rates had not yet been applied?
    The problem as I see it is people in this country are damned if they do and damned if they don’t. Most can’t afford health insurance and it offers such little value for the most part. By the time paying a bill comes around, patients have spent a majority of their healthcare budget paying premimus.
    Health care costs are going to have to be lowered to make things work. The physician and/or practice has to stop raising costs for the paying patient. I’m sure you’ve heard of “usual and customary fees.” Today’s ecomony is not usual or customary.
    If you really are concerned about reimbursement, the one to hound is the insurance carrier. Lobby for changes to affordable insurance plans and hold them more accountable for shoving off costs to the consumer.

    • southerndoc1

      Your husband wouldn’t pay your copay?

      • Payne Hertz

        The point being she was treated rudely and it is doubtful her full bill had been tallied and insurance reimbursement properly calculated at that point, since this was an ER visit.

        Her other point about the need to lower costs system-wide and not just foisting ever-increasing profits and greed onto the taxpayers and patients is valid. But reality-defying medical propaganda always accuses patients of paying nothing for this system while they are magically “insulated” from its costs, like the $2.7 trillion we spend on healthcare every year is paid for by doctors on our behalf.

        We need to be bled more as a means of controlling costs by making us use services less, or so goes the “logic” of this system’s defenders.

        • http://www.facebook.com/profile.php?id=100003366286858 Nurse Holt

          Well said. Of course, I wouldn’t dare question the necessity of a CT scan costing 2k right?
          I think I am more surprised by the sense of entitlement of the physicians than I am the patients. There is too much waste. Maybe one day when the Medicare and Medicaid system has run dry, the need will actually arise for healthcare to be sensibly handled.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    The author used a personal experience as an analogy to discuss health care payment and funding. The vitriol flowing back and forth on this board is inappropriate. The name calling is worse. The author ,a physician ,should have made arrangements to pay the septic tank repair man BEFORE the job was undertaken. Regardless of the doctors income, tax returns or budget ,medical families run into cash flow problems like everyone else.
    The health care debate over who pays how much and when is long overdue. The debate over whether health care is a right or a service needs to continue. It would be wonderful if the climate for the debate could be a bit more civil. Those advocating privitization need to read yesterdays NY Times front page article on Hospital Corporation of America and how they increased profits. The current election at the national level provides stark contrasts in philosophy about how a society will deal with its sick and poor and disadvantaged. Hopefully there will be a meaningful fact filled series of debates followed by a record turnout at the polls. That way the people will speak and announce their feelings at the polls the way we are supposed to.
    Just like the septic tank repair man needs to be paid to cover his bills and provide food , clothing and shelter for his family, the medical professional needs to be paid as well. The medical professionals numbers and earnings and budget may be different but with no incoming funds he will not survive long. We have allowed employers and insurers to dictate how medicine should be run and removed any personal responsibility from the equation until the cost of that type of policy became prohibitive. We have moved to a system where policies are still high but what they cover is minimal requiring individuals to meet those costs. As a physician I want to be paid but not at the expense of patients losing everything they have or not having access to care.

    • mediatechnology

      “The author, a physician, should have made arrangements to pay the septic tank repair man BEFORE the job was undertaken.” Really?
      OK, let me see if I got this straight: I walk into your medical practice as a cash-paying “customer” needing treatment and you’re going to be able to tell me how much it’s going to cost up-front? Yeah right…
      Shouldn’t our doc have time to drive to the bank and move funds from one account (perhaps another bank) to another?
      Even with insurance my wife is often told “Your co-pay will only be $xxx.” The out-of pocket is often many times that. Geeze I though I had a verbal contract. Not so in insurance/provider la la land.
      How about the next time I go to the doctor I receive up-front a fixed price contract for service? Then I could make preparations to pay the doc just like the septic guy. Ain’t gonna happen…
      So why should our septic guy – without anyone knowing what the repair or replacement is going to cost – be treated any different? I see his point. I’ve been self-employed Since 1982. I think 24 hours was reasonable.
      I’m sick of the welfare entitlement mindset as much as anyone. Government involvent in healthcare requires patients and providers to make a call to the worthless. The septic guy needs your support. Our doc knows this.
      You do want to keep the septic guy as your BFF because you will always need him to pump out the sewage. Perhaps we should send him to DC to pump out the swamp.

  • http://www.facebook.com/profile.php?id=639156794 facebook-639156794

    Dude. You’re a DOCTOR. He’s a PLUMBER. You get paid WAY MORE to clean up people’s …er…poop. So pay the plumber when he delivers the care.

    • John Henry

      We’ll that is the point, isn’t it? He doesn’t get paid “way more” for doing what he does as a doctor than his plumber does for work as a plumber. You completely missed the OP’s deliberate contrast as how it seems improper for him to stiff the plumber, and in fact not to pay on the spot, but that it is somehow OK to do just that to doctors. In fact, many of his patients feel entitled not to pay him at all.

      It was a modern parable, a little story to make the point.

      • Jane Infidel

        Yeah, but he shouldn’t take it out on the plumber. The plumber, so far as we know, never stiffed this doc out of money. That plumber might pay his copays every time on time.

        Personally, I think we need a cash based system like the plumber and free health insurance. People can choose whichever they want, so they don’t have to take part in national health care if they don’t want to. I say this precisely because money is such an issue for physicians. If they are guaranteed payment, they won’t be so pissed at patients who don’t pay

      • mediatechnology

        No one said he “stiffed the plumber” by asking him to wait 24 hours for payment.

  • Payne Hertz

    Okay, so you can afford to go on vacation but you can’t afford to pay
    the guy who performed labor for you $675, but then you are complaining
    about not getting paid the monopoly rents we as a society are forced to
    pay you as we are denied alternatives to dealing with your profession?

    The septic guy did what he was paid to do. Contrast that with ER doctors
    who will happily take $2,000 from those people with backaches and
    toothaches you disdain for coming to the ER, while providing them with
    no treatment at all, or maybe just 10 5mg Vicodin so they can say they
    did something for the pain. How many times do doctors and hospitals bilk
    patients with unnecessary tests, procedures and overcharges or how about the
    billions they defraud from Medicare and private insurance every year?
    Seems like all that might cover a delinquent payment or two.

    It is also a fiction that people receive “free” medical care for which
    hospitals are not reimbursed. Private hospitals are given tax deductions
    and grants to cover the cost of providing charity care, and Medicare
    alone provides over $40 billion a year to cover the cost of uninsured
    patients in hospitals. In addition, while treatment may be free at the
    point of service as with many other service industries, hospitals can
    and will pursue people relentlessly who owe them money, even when they
    have been granted aid money to provide that care:


    Your analogy might have been more accurate if you were forced to deal
    with the Septic guy as you were legally prohibited from getting the
    service elsewhere and pay outrageously inflated charges as a
    consequence. Maybe if the guy came out, looked at your mess and said
    “you’ll need a specialist for this” and then handed you a bill for
    $2,000 (average cost of an ER visit) while doing absolutely nothing for
    you, not even recommending a specialist. It would be more like medicine
    if he gave you a lecture on “personal responsibility” and how
    destructive it is to the environment and rude to your neighbors to let
    your septic tank overflow and how you are lucky you are not in the NYC
    watershed area, where you could have received a $20,000 fine for that

    It would be more like medicine if later on the do-nothing Septic guy got
    on his blog to complain about people like you and your lack of personal
    responsibility and how we as a society need to start getting tough with
    you rather than forcing society to deal with the consequences of your
    irresponsible behavior.

    The question you ask is “why does medical care have to be free?” when
    there is no such thing. The question we as a society need to ask is why
    are we forced to pay monopoly rents to a dysfunctional, misanthropic and
    greed-based medical system when we can have a more efficient and
    humane system at lesser cost. Why does someone with a toothache have to
    go to the ER and pay $2,000 for emergency pain treatment to doctors who
    don’t think this is an emergency and who often refuse to provide that
    treatment either for ideological reasons or because they think everyone
    with a toothache is a drug seeker? Why can’t that guy have a bottle of
    Vicodin in his medicine chest to deal with contingencies like this, and
    not have to deal with the system at all? The answer of course is profit.

    Why are so many of our laws set up solely to generate profit for
    doctors, hospitals and drug companies while denying American citizens
    our right to do what we will with our own bodies? You complain about not
    being paid, but never think what it’s like to be forced to either
    suffer or pay monopoly prices for our septic medical system.

  • http://twitter.com/tophere Christopher England

    Why should medical care be free? Why should access to public infrastructure be free? Why should education (through grade 12) be free? Why should books in the library be free? Why should fire or police services be free?

    Your premise is wrong. None of the above are FREE. Instead, they are paid for through the collective.

    Currently, the absurd prices for medical services are absurd because they take into account the services doctors provide non-paying patients. Analogously, the septic tank man could defend charging double or treble to cover the costs of the non-paying clients. But he doesn’t because he has the expectation of payment and because his competitors would eat his lunch by offering lower prices. When a patient visit an ER, s/he has no option to shop around for a competitive rate.

    A few changes to our broken system can fix many of these issues:
    - Create an expectation of payment (through universal coverage)
    - Provide a mechanism that creates downward pressure on the price of services (no clue how: inverse incentives to rising costs?)
    - Fix medical litigation (which puts upward pressure on the price of services)

    • snurfy

      Thank you Christopher!

  • http://profiles.google.com/andeevb Andee Bateman

    Maybe I’ve been awake too long, but I see some distinct confusion about the entire idea of payment. EMTALA speaks to the fact that under Reagan, we as a nation could not tolerate the thought that anyone would suffer a life threatening situation and die due to citizenship status or ability to pay. That being said, it was indeed entirely unfunded, which leads us to where we are today. But you actually have to go back much further than EMTALA, imho. Keep going back to 1972 when Mr. Kaiser himself, yes THAT Kaiser, sat in the oval office with Richard Nixon and profitized our healthcare system by injecting for profit insurance into the payment method, and ultimately killing non-profit insurance. Up until then, it was cash for services and non-profit insurance for catastrophic illness or accident. Yes, of course technology and specialization is more expensive now, but my OH MY, what a different world it would have been if that profit margin between many of you physician’s here and your patients had never been opened up, leading to the chasm we have today. ACA is the first legislation to address that broken preferred method of payment. For all the bitching and moaning about uncompensated care (which is perfectly justifiable – who wants to work for free?) let’s not lose sight of the real deal here. There’s an intruder in your pay cycle, and he’s taking a cut. Insurance providers diagnose nothing, they prescribe nothing, they initiate no treatment plan, rehab, evaluate, debride, excise or intervene in any way….except to take 27% of your paycheck. ACA is consumer protection to compel insurance companies to pay for the care they contracted for. By getting everyone in the pool, that health care dollar becomes 85% care and only 15% insurance, and uncompensated care eventually fades into history. Its bringing back a pathway for patients and their families to hold on to their wealth, and a way for doctors to never have to work uncompensated again. It may be messy and filled with painful transitions, but that is where it is headed. There’s a light at the end of that tunnel, and for the first time since 1986, its not the train.

    • klmwansa

      Well said.

  • http://www.facebook.com/patti.carrollfrey Patti Carroll-Frey

    I, as a poor person with multiple medical problems but also an an RN working a little bit, would never have considered calling a plumber without ready finances. Our basement floods regularly with sewage but I can call the landlord. Not for the clean up though. Medical care needn’t be free so much as it needs to be affordable.

  • petromccrum

    Many patients don’t expect free medical care; what we do expect are fair and reasonable charges for services rendered. Why should an ER bill be $1300.00 for a visit with no lab work, no medication, no tests. And that does not include the doctor bill. That is unreasonable and unfair. Why are all doctors now specialists; just to charge a higher copay. I have not seen the doctor;but the PA or nurse for my last 4 visits. That is not FAIR or REASONABLE. All of this on top of a $500.00 a month insurance payment. Doctors agruments are with the insurance companies not the patients.
    You should absolutely pay for your septic repair at the time of service. I cant tell you when is the last time I went to any doctors office and they did not DEMAND payment; sometimes before you even see the doctor; so don’t look to your patients for symphathy regarding your having to pay bills.

  • http://www.facebook.com/carol.levy.336 Carol Levy

    You need to find another profession.
    No medical care is free. It is paid for in one way or the other.
    I was on assistance for a short while waiting for my disability determination (which was granted, severe trigeminal neuralgia, atypical facial pain, atypical trigeminal neuralgia. I had to pay $7 for my visits to the medical clinic. The state picked up the rest, i.e. the taxpayers.
    You write this as to what is an emergency:“Emergency” means, in current parlance, everything from a painful tooth to sunburn, and of course, vastly worse things like lost prescriptions, heart attacks, trauma, and lack of confidence in a home pregnancy test.”
    When I worked as an ER ward clerk and started feeling the way you apparently do, callous and disregard for the patients – you equate heart attack with sunburn, I quit despite loving the job. It was unfair to the patients to be met with my negativity towards them.
    When I was having 12 brain surgeries and using a lot of medical dollars, everyone who was paying their insurance premium was paying for me, and when I stopped having all the surgeries, I started paying for those who are sick. That is what premiums are for. Medicare also pays in a timely fashion. You may not like the reimbursement but cash sent to you is not service for free.
    So no universal health care, no ACA, no bringing into the insurance pool 32 million uninsured Americans. Let them get sick and die because you as a doctor never heard of the hippocartic oath, or mere decency towards your fellow man.
    No medical care for the poor so the man with the untreated TB keeps spitting in the street and gives his TB to many others: that is why we have a resiliant strain. We have a whoopinig cough epidemic. Some, stupidly, chose not to get their kids vaccinated but I have little doubt that some of the carriers and spreaders did not get the shot because they could not afford it. But hey, they’re poor so to heck with them.
    You do not, based on your writing here, have the soul of a doctor. Yours is the mind of a bureaucrat.

    Carol Levy

    author A PAINED LIFE, a chronic pain journey

  • http://www.facebook.com/people/John-Wickenden/729562456 John Wickenden

    May I suggest as a non American (Brit in Thailand) that you Rebuild your system from the foundation up? And the foundation…..(gasps from the audience)…..is “How much do we decde to spend on healthcare”. Many will hate to hear it, but the economic decision comes first and foremost. If you can only get rid of your ridiculous litigation, not only legal insurance but much more important unnecessary testing by anxious doctors will reduce costs a lot. Follow that up by removing insurance from a place it shouldn’t be, and collective bargaining for pharmaceutical pricing and hey.
    Easiest of all, choose the best from Europe and institute it on pain of death. You will then get affordable healthcare and jump up from your pitiful p osition in the healthcare quality tables.


  • James Sinclair

    I would like to interject a bit of compassion into this downward spiraling conversation. Read “The Concept of Service in Medicine” by Stanley Joel Reiser, MD, MPA, PhD in J Pain Symptom Mange 2012;44:150-153. This is the “caring profession”

  • Dorothygreen

    Using cars or folks who clean septic tanks are not good analogies to health care. Actually, they are rather insulting to humans especially for a physician to use them.

    And that you didn’t have money in your account to write this guy a check is not quite believeable.

    Health care is much different than a car, a computer or someone cleaning septic tanks. Health care is not free and you know it. Someoneultimately pays. The ACA is a giant step in cleaning up the mess that has been made since Medicare – the compromise with the AMA and Republicans to allow “reasonable and customary” fee for service and hospitals to get additional funding. Then Nixon, and on up to Medicare part D – no attempt to fund.

    Switzerland started having problems with market driven health insurance and OUTLAWED it for basic care insurance. Alsom mandated everyone must have insurance. There are 1000 insurance companies in that country. The average adm cost is 6%. They can however, have market driven supplmental insurance – more choice in physicians, fancy hospital rooms, dental, eye glasses etc. Patients do have to pay upfront, (I don’t know up to what amount) but they get reimbursed within a week, the French have to pay up to $100 and then get reimbursed. The government insurance for low income folks. The government is responsible for seeing to it that insurance companies don’t overcharge patients or that providers don’t overtreat. Perfect system?, of course not, but overall higher marks than US at about half the cost.

    We can get close to Swiss model via the ACA. In fact, a number of ideas are perhaps taken from the Swiss. (OMG- the US looking at another country)

  • http://www.facebook.com/profile.php?id=1536821513 Edwin Leap

    Everyone, thanks for commenting. I’m not so thankful for the insults, but hey, as a writer you have to cowboy up and take it sometimes. So here’s the thing. I never, ever, said I wouldn’t pay this man. All I said was, I have to move money into the checking account or else the check will bounce. That’s all. I didn’t stiff him, cheat him, or even question his bill! What I sense from some comments is that whenever you receive a bill for a service, you immediately and without any pause pay the full amount. Correct? That is, you live and work in a cash only system. No credit cards, no accounts, whenever anyone works for you, you hand them the money. If that’s the case, awesome! But I doubt it. I suspect that even the physicians who are angry at me sometimes pay by check at a later date. But hey, hate me if you must.

    I honestly had no idea how much it would cost, and it turned out to be more complex than expected. I would have paid far more to avoid having the tank back up again.

    Of course, he immediately spread the word that ‘that doctor isn’t going to pay me.’ I heard it weeks later from folks separated from the situation! I never said that.

    Now, as for ER bills, they are high. No doubt. And if we had a cash based system, especially if we had never had insurance at all, it’s likely costs would be much lower. But everyone likes insurance, which in fact raises prices (just the same way federal money to universities raises tuition). Of course, the ER is mandated to see everyone; so, to cover costs (yes, I have them since I am not employed by the hospital), prices are higher than they ought to be so that insured patients do bear the brunt of the cost. Fair or not, it’s a perverse turn on socialism. I don’t really like it, but since I see so many people for now compensation, it’s how I make my living. If someone wants to pay all my benefits, and cover my malpractice insurance, we can talk about charges.

    Does anyone get the point here? It isn’t that I hate the poor. I take good care of all of my patients, paying or not, and I love caring for them. So don’t dare tell me I don’t unless you have been my patient. And enough with ‘you need a new job.’ You have no idea how hard I work and how well I practice medicine, or with what compassion I do it. I was simply railing against the odd disparity with which we view payment, the things we consider important and ‘emergent’ and the way physicians are always considered to be rolling in cash! That’s all.

    Thanks, also, to my defenders!


    • http://www.facebook.com/profile.php?id=662132748 Lata Potturi Schaedler

      I got your point. I enjoyed the article AND the comments (as I always do).

      Many physicians (including myself) share your viewpoint. We would never expect our septic tank to be repaired without paying immediately for the service. Yet, we are expected to deliver medical care without the promise of payment. Yes, the scale of expenses and cost of living may be different, but that should not matter as the investment into our career with regards to student loans and length of education are different.

      Physicians, by and large, are a poorly organized group of people who are an easy target for the public who is outraged by medical costs. They have no idea how little physicians get from that $1300 medical bill. Largely it goes to paper pushers who have no interest or concern about their well being at all.

  • Sopvah

    Ok, all bickering aside. Why couldn’t you have gone on line and transferred the funds? You were at home, so you probably had access to the internet. Just a thought.

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