If the Price Is Right

Over the last few posts I discussed a few reasons as to why our health care costs are so high in this country and also how the control in health care expenditures has become intractable. Even with this large and uncontrollable health care spending there are over 46 million citizens uninsured in this country. An increase in the number of uninsured is partly due to the lack of employer-based health insurance. Since the start of the recession, roughly 500,000 working aged Californians have lost their jobs. This, and the fact that some employers find themselves struggling to insure their current employees, is going to significantly contribute to the amount of uninsured people.

That's when public coverage comes in. Programs such as SCHIP have actually curbed the amount of uninsured in this country by covering children whose families meet certain income requirements. Also, the American Recovery and Reinvestment Act of 2009 (ARRA) will allocate a large sum of money into other public programs such as Medicare. The ARRA designates $150 billion for health care-- with $86.6 billion of that going straight to Medicare.

However, what good is it to give out health insurance if doctors won't accept it? According to Julie Connelly of the New York Times, many more doctors have been turning down Medicare and Medicaid payments. Connelly notes that some doctors have "opted out of the insurance system" altogether, or "they are not accepting new patients with Medicare coverage." Most of these doctors are internists and primary care physicians, but specialists such as gynecologists and psychiatrists have also been rejecting the plans. The reasons why aren't new or unusual: "reimbursement rates are too low and paperwork too much of a hassle" states Connelly.

Reimbursement rates are too low they say. It is true that physicians aren't reimbursed the full amount charged for an office visit or procedure through Medicare and Medicaid. The typical reimbursement to the physician is 80% of the actual fee charged. That doesn't seem that unreasonable. Especially in light of the fact that, as I said last Tuesday, the fees that physicians in the U.S. charge for general lab tests, procedures and office visits are typically 30% higher than what their counterparts in Canada are charging.

I can see their frustration to an extent. A doctor will complete a certain amount of work and charge the system accordingly. Thus, they expect to see that money. They've most likely calculated their budgets according to that pay scale. And above all, they earned it. So, when they aren't getting the remuneration they expect it is probably very discontenting.

However, there seems to be more to it that just that. For starters, not all doctors are opting out of the Medicare system. As Connelly notes, "a 2008 survey by the Texas Medical Association found that while 58% of the state’s doctors took new Medicare patients." This is very similar to the percentage of physicians who support single-payer national health insurance in this country. A 2008 report showed that 59% of physicians support this idea while 32% reprove it.

I believe the two polls express opinions concerning one underlying concept: autonomy. Both the Medicare situation and opinions regarding single-payer national health insurance deal with physicians having to relinquish a certain amount of autonomy in their practice. That autonomy is the freedom to charge what they wish.

I am going to take two excerpts from Dr Donald Barr's (MD, PhD) book Introduction to U.S. Health Policy that shows two disparate positions regarding this autonomy in more detail. The first is from Dr R. M. Sade and was published in the New England Journal of Medicine in 1971:

"Medical care is neither a right nor a privilege: it is a service that is provided by doctors and others to people who wish to purchase it".

On the other hand, we have the position of Dr. John Bowman who released this statement in 1918:

"As a people we are accustomed to hospital service; we look upon that service no longer as a luxury which we may buy, but rather as an inherent right...we regard the right to health today as we regard the right to life".

In the former view, either you have the money to pay what a doctor will charge or you don't. These are the doctors who feel they shouldn't have to comply with a system that won't let them freely charge what they wish. The latter view suggested that we should all be able to receive care when necessary. If that means accepting a discounted rate on services or supporting a single-payer national insurance system than so be it.

I interpret the former view as one that flirts with selfishness. And being a doctor requires a bit of something quite the opposite: selflessness. The motivation to be a doctor seems that it should stem from wanting to help others even when the price isn't right. Although I understand, not everyone can walk around wielding their services for free. No one can live off of that, and certainly no one expects their doctor to work for free.

The main point is: doctors do and will still get paid if they accept Medicare payments. The same goes for a single-payer insurance plan. Also, a doctor still has complete autonomy over how, when and in what manner they wish to wield their services. They are no-less a physician because of these systems. So which price are physicians willing to pay in this country? The price of fiscal autonomy? Or the price of health for their fellow citizens?

- m.tsang