In interesting discussion in the AMA. It appears they feel physicians have an ethical obligation to provide care, regardless of the patient's ability to pay.
So long as it is fiscally sustainable for physicians, the policy says, doctors should accept uninsured patients and maintain relationships with patients who lose health coverage. Doctors should help patients access public programs and charitable sources. They should take part in the political process to cut financial obstacles to health care access, delegates said.
A very noble policy to institute. To bad nobody can define "fiscally sustainable". For some physicians that might mean $100K a year in income. For others that might mean $1 million. It is not for anyone to judge what is fiscally sustainable for a physician's lifestyle. That is a personal decision only the physician and their family can answer.
Of course all would be fine and dandy if the grocery store down the street accepted the smiley faces and fuzzy snuggles as payment in full that you receive from your ethical obligation to nonpaying patients.
The AMA has it all wrong. Physicians have always been a very charitable group of folk. Not because of an ethical obligation dictated by an organization that has lost its way through the years, but rather out of a self inflicted viral desire to help others, on their own terms. Mandating charity as an ethical obligation is the same as mandating all physicians accept Medicaid or Medicare. That makes you a slave of society.
As practicing physicians who operates under the US monetary system we are bound to play by capitalism's rules. Your landlord does not care about your ethical obligation to provide charity care. Your kid's dentist does not care about your ethical obligation to provide charity care. Your accountant and lawyer do not care about your ethical obligation to provide charity care.
Whether to be charitable or not is a very personal decision. One that cannot be codified into ethical mandates from aging institutions. If you as a physician lose your ability to provide free care on your own terms, based on your own value system, you become nothing more than a slave of society. An ethical mandate devalues your years of training to nothing more than a societal right. A right that places you in a position slavery and not one of free will to provide charity on your own terms. The fact that the AMA feels an obligation to codify the ethical obligation to charity says to me how out of touch they are with the realities of the economics of today's medicine.
The new policy comes when declining physician income appears to be affecting the amount of charity care doctors provide. A March 2008 Milbank Quarterly report found doctors' pay fell 7% from 1996 to 2005, when adjusted for inflation. In the same period, the proportion of doctors offering charity care dropped 10% to about two-thirds of physiciansPhysicians are saying, that their ability and or desire to provide charity care is inversely proportional to the financial situation they find themselves in. It has nothing to do with ethical mandates and everything to do with personal financial decisions. If you want more physicians to provide more charity care, you're going to have to pay them more to do so. And that has nothing to do with ethics and everything to do with economic common sense.
16 Outbursts:
I wouldn't be surprised if the decline in charity care is due more to the decline in job satisfaction. I know broke ass mechanics who have always been willing to help a friend out after work. It's not really charity care if you're getting paid for it.
People often wonder why physicians such as Happy have so much resentment about the whole subject, and I'm sure his post, as always, will incite some readers' anger. Allow me to try and explain:
You sacrifice some of the best years of your life (basically all of your 20's, in most cases), work incredibly hard, and go into a huge amount of debt to become a physician. You chose this, though, so you suck it up.
Then, the government and a large swath of society run around proclaiming that everyone has a right to your skills and the hard work, time, and money, that went into acquiring them. Healthcare is a right, they cry. The same way I have a right to speak and write freely, to worship whatever God I please, and to vote in elections, I have a right to physicians' abilities and skills.
The difference here is that the right to free speech, the right to assembly, and the right to choose whatever religion you like don't impinge on other people's freedom. If you want to write a tirade in response to this blog, go ahead. Get your friends and protest if you like. These are your rights. It doesn't hurt anyone else.
When people view healthcare as a right owed to them, rather than a privilege given to them, the attitude changes from one of gratitude to one of demands. Society has a name for demanding something of someone else without their consent to take it freely or an intent to pay them an agreed price for it. It's called robbery.
Does taking my wife to the hospital to give birth count as a "nice thing to do today?"
Fend for yourself hits the nail pretty square on this one.
Hi Happy,
Once again, working to give our profession the good name it deserves.
While I agree the AMAs attempt is alot of fluff with no teeth to it,it seems our profession should indeed remain one that takes care of its community when times get tough. The past years of Wall Stret greed have seemingly made everyone jealous of the increible incomes that these guys have made, along with there fellow CEOs, that has made us all feel like we are all being taken advantage of, and should be compensated more generously for our incredible sacrifice. I personally found medical school and residency to be one of the more exciting times of my life and by no means a sacrifice as one of your posters claims. If you choose to take on years of training, do not expect that a big pot of gold awaits you when you get done simply by virtue of the number of years you put in. Otherwise we would have alot of well off English and Philosophy PHDs running around caliming how many rigorous years of training they have and how they sacrificed the best years of their lives.
It is time that we all look to what can make medicine more affordable and equitable for everyone, which is what the current administration that you seem so critical of is attempting to do. Then we won't have to worry about whether our patints can afford the treatments they need or not. The the whole issue of charity care and who delivers it can go away and we can concentrate on improving the overall quality of the health care system rather than trying to figure out how to avoid our responsibility to the under and uninsured.
Keith, if you believe that an english or philosophy PHd is in any way equivalent to medical school/residency, well we are speaking a different language.
I don't think false equivalency helps the discussion at all. 12 years of post-baccalaureate study at 100+ hours a week, followed by late night phone calls etc has no relationship to being an english professor.
The current administration is looking to make medicine more affordable and equitable. Unfortunately, his idea of equitable is that everyone gets poor care. That kind of equality I can do without.
Keith, we disagree on how to make medicine affordable. When was the last time you saw anything from the government affordable. You place your faith in the government. The reason health care is so expensive today is the massive regulatory demands placed on everyone from hospitals and doctors to drug makers and device manufacturers.
You look to the government as the solution. I see them as the problem.
What we have no is a 99 trillion dollar unfunded mandate. Government, in the history of time, has never gotten smaller. What we will have with Obamacare is a 99 trillion + 1 trillion. Then it will be 99trillion +2 trillion...then it will be 99 trillion + 3 trillion.
I say often I could triple or quadruple the number of patients I see if I wasn't jumping through so many hoops to get paid and not be accused of fraud.
You are incredibly naive if you believe the government has the ability, or desire to be the keeper of your health. In fact, their desire to remain relevant by buying you off. And in the process, the inability of government to say no to you will be its own downfall.
Oh yeah, one more thing, no government in the history of time can make medicine affordable and equitable for everyone by being both the supplier and demander and printer of the money. It's doomed for failure, as we have seen the government run Medicare National Bank drive this country into the ground.
99 trillion dollars. That's right. 99 trillion dollars
congrats county. That's great!
Happy,
You still fail to tell me why other industrialized countries with socialized medicine have half the costs that we have and health quality measures that at best show no ifference and are often better than here. Until you explain why our goverment is so inept in comparison to these other examples (France, Britin, Germany, all the northern European countries, etc, etc.), you have no valid argument other than what your core beliefs are. Give me one example of an inustrialized country that has a goverment run health system where the citizenry is in an uproar and wishes to get rid of their present system and I will acede to your argument.
By the way, you seem to put more faith in the health insurance industry to restrain costs (they certainly have done a great job in that area!). I personally think the goverment wins this one hands down.
I have done both English advanced degree and medical school. There is no comparison which is harder and more expensive (it is med school/residency in case you weren't sure Keith).
If you take away financial incentive you get worse workers. My favorite economics quote: "It is not from the benevolence the butcher, brewer and baker from which you get your dinner, but rather it is out of their own self interest." - Adam Smith.
By the way Keith,
When people talk about "greedy CEO's and people on Wall Street" why do they never include the greedy entertainment figures? Why isn't Oprah "greedy." Why isn't A-Rod "greedy?" Why isn't Alec Baldwin "greedy?" Why isn't Stephen Speilberg greedy?" Just curious Keith? What is the difference?
Keith you miss a lot about socialized medicine.
Lets start with the population. The european/canadians have very low expectations when it comes to medical care. They tend to be more stoic in general, and years of poor treatment has hardened them against high expectations.
It has been demonstrated a number of places on this blog that the outcomes are worse in countries with socialized medicine as well. But lets look at things that are hard to measure.
When training in Sweden at a very famous hospital, I was observing a procedure that here in the states is performed as a MAC case. That is, an anesthesiologist administers IV meds to sedate the patient before the procedure is done. Local anesthesia is also used. At this famous Swedish hospital, the surgeon literally left the patient in the wheelchair, told her to hold still, and injected the local.
Now the procedure itself was similar in both instances. I won't go into details about why the swedish practice was not as good as ours, but will say that you will not measure a change in outcome. But what about the care of the patient?
Or will you just argue that we are all wimps here, and could as easily just bite the bullet and suck it up, as you suggested earlier in your comment suggesting that chemo just made the extra lifespan miserable?
The beauty of Keith's argument is that to him, it still is voluntarily charity care. You see, Keith, in a way, chooses to provide this care. In his mind its not slavery because his charity of choice is the government. Thus, he still gets warm fuzzies because this kind of socialist agenda works for him.
Well I don't get warm fuzzies. And I for one don't give a **** if you think we're avoiding our responsibilities to the un/underinsured. I absolutely refuse to give my patients substandard care. As Ricky Bobby would say, "I piss excellence." Heh. Bottom line, the patient and the guy with the medical license gets to decide the treatment. Not some government committee. PERIOD. Furthermore, I'm terribly impatient. I hate waiting. And, I bet if I had cancer or needed open heart, I'd REALLY hate waiting.
Problem here is, the government doesn't like competition. When you create and increase government entitlements and decrease the tax deduction to give to charities, you're sending a pretty clear message. If the government wasn't so busy mandating utterly tedious paperwork, disproportionately increasing our taxes, cutting our reimbursement, availing us to frivolous lawsuits, and turning physicians offices into time-crunching assembly lines, there would be so much collective good will left in the medical community that we'd be long past caring for this country's uninsured and on to other countries who desperately need us.
FFY...stunningly eleoquent posts, and the first sums it up quite nicely.
My only additions would be to inquire how much "moral" responsbility Jane and Joe Sixpaq have to minimally maintain their OWN health, as much as that is possible. Why should anyone in healthcare care MORE about a pt's health than THEY care about their own wellbeing.??
In addition, where does the government come off speaking about morality?? With "tolerance" and "diversity" being the only gods recognized as valid, who gets to decide morality in the absence of a Judeo-Christian set of ethics?? Haven't they heard that "right and wrong" are antiquated and unjust, just opressive ways of raining all over my free choice??
Well, until I need a doctor, at least.....
Pattie, RN
In the absence of charity or resident clinics that treat the same condition, make a happy medium and charge the patient up front what Medicaid would have paid for the same patient. The majority of uninsured people are ages 18-24, so it's not like you're going to be dealing with a ton of pathology anyway. If you don't treat em, they're coming back to the ER.
Fend for yourself,
Under your argument, if you come accross a man bleeding, and you don't have anti-septic and sutrue material to properly sew up his wound, it is better to just let him bleed to death.
One has to define what is the "best care". If you insist on offering the "Best care" to your community, but only 50% of your community can afford the best, what do you suggest the rest do for themselves? Get substandard care? Why not try to offer the best care to all and try to give up that new BMW you have had your eyes on for quite a while.
And Keith wins the Kewpie doll......
Keith in America, far greater than 50% can afford the best care. In fact, far greater than 90% can. What you want is to dumb down the system so that the 90% suffer for what 10% can't get.
That is just dumb.....
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