Can I pay for it?

One of the frequent and revisited notions in healthcare today is, “Can I continue to afford to go to the doctor?” This subject brings up ethical, legal, and often opinionated questions. Why is healthcare so expensive? Why is my insurance so expensive? Why doesn’t it cover anything anymore? Why do I have higher co-pays and deductibles? Why isn’t my doctor affordable? Well, there are many possible answers to these questions and perhaps answered by unfortunate general terms such as pride, detachment, and my favorite, greed.

Michigan has been in the throws of economic chaos for the last few years. All indicators are that it will not be much better anytime soon. This leaves a bad taste in patient’s mouths when it comes to healthcare. Too many times I hear the statement, “What do you mean I have a $40 co-pay, or a $1500 deductible? I never use to pay a dime to go to the doctor!” I think my generation has become accustomed to the historical insurance parameter of little to no out-of-pocket care. It has left the impression for weal or woe, that people believe that they shouldn’t have to pay for healthcare. Now, it costs considerable money from the patient to see their family doctor, chiropractor, or specialist. Let us break it down.

Health Insurance: Remember these jingles:”Like a good neighbor,” or “You’re in good hands.” Though the preceding jingles don’t necessarily equate to healthcare, you don’t quite feel that health insurance companies put you first anymore. Why is that? Because like most corporations, their primary interest has become profit reports, and happy stock holders. Even the nonprofit companies are recording huge profits, and paying million dollar bonuses to their CEO’s. With the internet and multimedia reporting, it is hard to discern where credibility lies, but one report suggested nearly 800 billion dollars last year in health insurance profits and administrative fees. That is better than 60% of our national debt. So when we see annual increases in insurance premiums in the vicinity of 11-16%, escalating deductibles and co-pays we can be sure of one thing: Insurance companies are charging more and paying less. I guess we can chalk this up to old fashioned greed. The problem is that many of the advisory board members to the large corporate insurance companies are judges, legislators, and stock holders. Conflict of interest you ask? I think so. Medicare has reported an annual 3% margin (give or take minimal error). One would think that the private sector could reasonably perform close to that. Don’t misunderstand me, I am not in favor of national healthcare for a plethora of reasons: quality of care, tax burden, choice of care, gatekeepers for portal of entry, and many other ill-defined parameters to the current Obama bill. Most importantly, it is absurd to think that a bean counter will determine what is the proper healthcare, and instruct the doctor on what he can or cannot do. There is a great book that clarifies much of this: The Awakening of a Surgeon, by David H. Janda, MD. At this point, it appears that national healthcare will never see funding. This is probably a profound blessing. Let us face it, the private sector is failing miserably. Our country regulates housing and agriculture. It is time to put limits on profits and administrative costs in the health insurance market.

Pharmaceuticals: One study reflected a 27 cent markup on the penny. That translates to an average 2700% profit margin by big pharma. Why can we go on-line, buy drugs from Canada (that were synthesized in the United States), and buy them for a third of the cost? Our Lawmakers allow the FDA to be run by the CEO’s and Board members of big Pharma. More conflict of interest? Greed? Probably both. Profits are more important than the health of America’s citizens. I believe that Big Pharma should make great profits, but reasonable profits. Again, more regulation on this essential industry is the probable medium to reasonable care.

Physicians: There is an old riddle that goes as follows: “You see a rich doctor, a poor doctor, and Santa Clause standing on a street corner. They all look down at the same time and see a $20 bill. Who gets it? The answer wittingly states, “The rich doctor, because everyone knows that Santa Clause and poor doctors don’t exist.” Pretty funny when you think about it, but it clearly states the perception on doctors and their income. It seems that there is a sizable portion of the population resent the physician’s income. I am sure a considerable amount of surgeons, specialists, and medical entrepreneurs make sizable incomes, but one needs to put in perspective the amount of investment and sacrifice a physician makes to become licensed. The average physician puts in 12 years of education with undergraduate, medical school, internship, and residency. The average physician will graduate with a student loan balance in excess of $275,000 (which is incidentally more than most mortgages). Physicians sacrifice many years and begin their careers worth huge debt. The earn their respectable incomes. We are already seeing a trend where medical school enrollment is declining and in certain areas of the country, a shortage of primary care physicians. In addition, the Obama administration is launching an increase to government branched employees, linked to the IRS to audit doctors, for the sole purpose or recovering “over payments.” The last report I have read estimates that between 3-4% of physicians commit Medicare fraud. However, on recovery audits, they will demand over five times that amount returned. The federal employee costs to the taxpayers may be higher than the actual recovery. Now, our government plans to punish the other 96% of physicians, by making the documentation and paper trail so extensive, doctors will lose actual time in patient care, or be force to hire otherwise unnecessary staff to help with the documentation.

On the other hand, doctors are under the gun to document and be very careful on how they give patients financial breaks when circumstances warrant it. We often are grateful for a physician that portrays warmth and compassion. Many caregivers will work with patients on financial concerns, albeit on a limited basis. Doctors must establish financial limitation, a need for care, a diagnosis, terms and plan of treatment. If a doctor (or healthcare establishment) fails on any of these, they may be accused of multiple fees (which is illegal). Recently I had a patient come in without of state insurance through which I was not networked. Our staff couldn’t reach a representative of the insurance that date. The patient was sure that they had coverage, however they were not aware of the provisions in their plan. We later discovered that the patient only had in network coverage for chiropractic, but with a huge co-pay. The patient expressed concern over costs, so we were able to offer special consideration to the patient that was half our original fee and less than the in network co-pay. However, the patient believed there was an agenda to the terms of care. I explained that they could terminate care immediately if they were not satisfied. They were not appeased by this and refused to the terms of care. I was forced to charge the patient my customary fees. In turn, they angrily called me greedy, evil, etc. Physicians are increasingly faced with the quandary of keeping a positive image while being forced to charge their patients greater out-of-pocket expense. Most conscientious physicians will attempt to work with patients if they have the control to make that an option. Many physicians associate in corporate healthcare systems. They do not have the authority to compromise their fees. Those that do, must be wary of the cost of maintaining practice. I bring this to light because there is a “front-line” we face in the healthcare delivery system. We must pick our battles together as doctor and patient. Until then, the only winners are the health insurance industry, big pharma, and the legislators that protect them.