As physicians, most of us love how we can make an enormous impact on others by saving, extending, and enhancing lives with knowledge, skill, and compassion. Our white coats symbolize a commitment to uphold the modern Hippocratic Oath: “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.”
However, many physicians who are in private practice–and who also treasure the ideals of the practice of medicine–have some of the most difficult battles to fight. One of the hardest parts of the dual role of “medical practice owner” and “healthcare provider” is the escalating war between economics and ethics.
At the end of nearly every month, I get a stack of charts (yes, we can’t afford to have electronic medical records yet) with a notice on them from my biller stating, “Do you want to send these patients to the collections agency?” Those are some of the most dreaded days of the month for me. I look at dozens of charts every month….some from family??? some from people who have little money….some from multi-millionaires…some from friends… some from people with fictitious names whom I saw in the hospital who had no medical insurance….and the list goes on and on…..and on.
It is excruciatingly painful to see tens of thousands of dollars of procedures done, hours of questions answered, 2:00 AM consults done, after hours phone calls made, tests ordered, other consultants contacted, notes dictated, charts prepared, staff hours used, supplies used…..all not-reimbursed. But why are so many patients not even trying to pay for even a part of their medical bills? These patients were sent three letters and received two phone calls that their payments were long overdue. Do patients feel “entitled” to have their healthcare covered completely? I try to rationalize it every time..….Some patients who are family and friends may feel that they should get a free pass. If they have no insurance, some may feel that they still have the right to obtain free healthcare. If they are millionaires, they may feel that their insurance should have covered the visit–even though they may have a $6000 deductible and limited medical office benefits. Some patients may feel that the doctor charged too much, or they weren’t happy with the care they received. Some rationalize, “Doctors are rich anyway. They drive fancy cars, they have fancy houses….. I am sure that one missing payment won’t cause them to lose their livelihood!” Well unfortunately, “going broke” is not a far-fetched reality for some doctors.
Five years ago, I met a very nice internist in the hospital and we quickly became friends. She was compassionate, thorough, and patients adored her. Her practice was very large and was growing rapidly. She would send me four to five patients a week and kept my practice very busy. One day, I found out that she was interviewed by our local newspaper about the reality of bankruptcy. Why would she be interviewed about that? Didn’t she have a thriving practice? Well, her story was that she had a thriving practice that would never pay for her services and she could no longer sustain her practice. She left the state and shut down her practice.
As doctors, we simply cannot watch patients who need urgent care suffer without treatment–whether or not they can pay. We have an ethical obligation to help others. It is hard for us to discontinue care in our office for patients who cannot afford it. It is also frustrating and time consuming for us to have to constantly make decisions about who can get away with not paying and who can’t.
We need to come up with better ways to avoid having to make these difficult decisions in the first place. There are constructive ways in which some doctors are able to avoid the battle between our moral obligation to save and protect health and our fundamental right to be compensated for our hard work.
Some doctors reserve a half day (or even a full day) a week to provide free care for patients. Some doctors enroll in national non-profit programs where they see a handful of patients a year at no cost. Some doctors provide medication samples for the economically disadvantaged through special drug company programs. Some doctors offer payment plans so that patients with financial hardship pay small increments every month.
I also propose that we implement some new solutions to help physicians who must simultaneously juggle the roles of both “caregiver” and “business-owner.”
1. Private doctors who see uninsured patients in hospitals have the right to get paid–either by the hospital or the government–if the patient has not paid the doctor for his/her services within 4 months of the date of service. Most hospitals are non-profit and often get subsidies, donations, and tax breaks for taking care of patients who have no insurance or cannot pay for care. Private doctors cannot be left with absolutely no remuneration for their sacrifice, expertise, time, and hard work. We cannot assume that physicians can continue to bear the burden of uncompensated care. We need to institute a mandatory policy ensuring that providers receive direct compensation from the government (if the facility is private) or from a non-profit hospital (if the facility gets tax breaks from the government) in the event that a non-insured patient does not pay a private physician for urgent or emergent care (where I practice, these programs/policies have all been dismantled).
2. Sending patients who do not pay to collections agencies should be considered a “standard and customary” practice. Doctors should not harbor feelings of guilt when they send patients to collections. Proper measures, such as sending out several notices and calling the patient, need to be taken first, and patients need to be informed prior to receiving care that they will be sent to a collections agency should they fail to pay their balances. Getting agencies involved to collect outstanding debts from patients should be “expected” and should not be construed as a greedy or malicious scheme by some doctors who “are out to get” patients.
3. It is acceptable to request evidence of financial need prior to offering discounts or waiving fees (this is standard practice for hospitals and so doctors should be entitled to ask for proof as well). There are patients—who are more than capable of paying for care–who take advantage of the professional courtesies that some physicians offer. By asking for evidence of financial need, doctors have an objective basis for which they can agree to write-off fees for those who are legitimately experiencing financial hardship.
4. All doctors need a reputable place where they can refer patients who are unable to afford medical care. As part of the Affordable Care Act, there should be a mandate that every medical facility (including doctors’ offices) be provided with an easily accessible online directory of free healthcare clinics in every city in the country where those who are in need can get urgent, preventative, routine, and all specialty care quickly and efficiently. This will help with freeing up emergency rooms and it will allow private practitioners to easily refer patients out who cannot pay for their services with the confidence that patients will not be abandoned and will be well-cared for. If there are no available or accessible free clinics, and patients cannot afford to pay for care regardless of their insurance status, physicians should be able to receive a government subsidy to care for these patients.
When a plumber comes to fix your toilet, you don’t get services unless you pay. You want to eat breakfast at Denny’s? You are expected to pay for your food—no ifs, ands, or buts. When you stay in a hotel, you must pay for your hotel room. The expectation to pay for physician services should be no different.
While I believe that we should all have access to healthcare, we cannot keep assuming that physicians can provide this care for free. Between 2008 and 2012, multispecialty practices saw their bad debt go up 14 percent, according to a survey by the Medical Group Management Association (MGMA), a trade organization for doctor practices. That’s money that practices were owed but couldn’t collect. If patients (low-income and high-income) continue relying on doctors to “foot the bill,” we will drive all private practice doctors into extinction. And until that happens, medical practices will transform (some of them have already) into cold, over-saturated assembly-line clinics: 70 or more patients will be shuttled into and out of exam rooms every day so that rushed and unhappy doctors can defray the cost of patients who don’t pay for care.
Dr. Henry Gold Editorial Writer for DoctorCPR.com
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