Is it unethical for a doctor to refuse Medicaid and Medicare patients?

[Gravitycollapse]

I see a lot of doctors refusing to treat Medicaid and Medicare patients because they don't make as much money. That seems pretty fucked up and greedy to me.

[KT2000]

1. The local Lutheran church

started afree/low cost clinic in our area because so many doctors were turning away Medicaid and medicare patients. They were surprsied when the majority of patients wereyounger working people who could not afford insurance or had such high deductible insurance they could not use it.

The whole mess is unethical but something that really bothers me is that with all the political clout that doctors have, most do not seem to use it for changing to system to make it more ethical and fair.

[MrSlayer]

2. Why would they?

Making things more fair and ethical does not equal more money. And everything is about more money. People don't become doctors to help people (well some do), they do it because it pays very well. Why would you advocate for something that hurts your wallet?

[bubbayugga]

7. Most doctors are half a million dollars in debt when they come out of med school

What do you think that translates into as a monthly payment? and they do work for free for their first three years out of med school. BTW, should lawyers take cases for free too? how about dentists? Plumbers? Teachers?

[MrSlayer]

8. Of course not.

They shouldn't work for free. College should be free. It's because of the loans and such that they have to pay off that the quest for more money becomes more important than helping people. Once the loans are paid off, looking to make back the money that was "lost" leads many to decide that they'll only take patients that are lucrative.

I did qualify my remarks. There are a lot of good people in the medical field.

[tallahasseedem]

36. I totally agree with you...

there are times where the office can actually lose money by accepting Medicare/Medicaid.

[onyourleft]

22. They work for...

...free? Perhaps I'm behind the times, but the many, many physicians I knew made a salary the first three years out of medical school. It may not have been a great salary, but they did not work for free.

[IdaBriggs]

98. 90 hours a week divided by $65,000 per year

Equals approximately $15 per hour. Cover housing, car, student loan debt AND give up on spending time with your spouse/significant other or (heaven forbid) a child during that time...

It is a stupid system. NEVER schedule elective surgery when the new residents start in June/July because that is when the most medical mistakes occur.

Note: just my observations from friends in the field. Others with better knowledge may have more accurate information.

[Egalitarian Thug]

38. Health care, Education, and Justice are the three modern necessities and should be socialized. n/t

Of the three, I'm pretty sure that the teachers are the only group that would get behind this idea.

[MannyGoldstein]

102. Average is actually $150k...

They'd like us to believe that it's a half mil, but the real average seems to be more like 150k. Which they can pay back pretty quickly, because they are guaranteed a wage that is multiples of what the proletariat earns.

[bubbayugga]

133. One of the docs I work with can't afford an iPhone.

I have an iphone. He can't afford a new car either. I can. He and another one recently told me they each racked up around half a million in debt by the time they were done. I'm sure he was taking loans out for housing too. He's also raising several children. It isn't cheap and they do work for chump change when they do their residency. I think they certainly deserve to be paid and paid well for their hard work.

[JDPriestly]

137. That's possible -- if you specialize and if you have to pay for your

undergraduate costs out of your loas.

Medical school alone without extra years for a specialty and assuming you are smart enough to go to undergraduate school on a full scholarship is $250,000- $500,000 now.

I stated that it was $250,000 in another post and then I began to think how costs have risen. $500,000 is probably pretty accurate now.

[JDPriestly]

136. The average may be $150,000, but it depends.

If your parents are rich, you owe nothing. If your parents are poor, you owe maybe twice that depending on what school you went to. that's the problem.

[antigone382]

37. I know of a doctor who practiced in Canada for a while.

He loved the system up there; never having to worry about whether patients had insurance before treating them, being able to give everyone adequate care. He is thankful that in his new job as a hospitalist the patients he sees are already "cleared" in some form or another; he doesn't have to worry that lack of ability to pay will prevent his being able to treat them. However, there is an awareness that for each patient he sees there are several who he doesn't.

This particular doctor is not a rich man, as far as I know; he has five kids and I believe he moved back to help support his wife's family. I don't know the details of his income or his bills, but I know that for him, a system where everyone has access to adequate care is far more satisfying than one in which many don't.

[Egalitarian Thug]

39. People should go into medicine out of a desire to help people, not to get rich or die trying. n/t

[IdaBriggs]

99. Mechanics should go into the field out of a desire to help people.

Fill in the blank - most professions are performed for PAY. People who spend 23 YEARS training to help people need to be compensated for the time they miss establishing themselves.

[Egalitarian Thug]

124. No one said that anyone should not be paid, I think you are capable of understanding that.

Doctors in Evil Socialist nations are paid and they make a very nice living. They have very nice houses and can afford really nice cars and their families want for nothing. They are pillars of the community and can join golf clubs and can afford to enjoy their five or more weeks of vacation in any way they choose. And most of all, when they are not otherwise occupied with this very nice life, they spend almost all of their time helping patients to heal.

What they are not are walking financial institutions. Very few of them go through the years of difficult study and what amounts to more years of apprenticeship so that some day they can buy an island, a dozen houses, and a fleet of jet planes so that they can spend the rest of their days figuring out how to avoid paying taxes.

Profit is a terrible motivation for a variety of professions because it attracts exactly the wrong people into the profession.

Are you going to argue that nobody does anything without the promise of a fortune at the end? Better still, answer this honestly to yourself. You have cancer, who would you rather have directing your treatment, the guy who is fascinated with the mechanism, behavior, and treatment of this mysterious disease, or the guy who became an oncologist because it comes with an impressive investment portfolio?

Was Jonas Salk a sucker for refusing to patent the cure for polio?

[IdaBriggs]

161. TWENTY-THREE YEARS of training means they will need to be compensated

Last edited Thu Mar 21, 2013, 01:26 PM - Edit history (1)

at a higher rate than the guy who drives the garbage truck or even a fireman/woman who rushes into a building to save people just to get to the same place in life at age 63.

Why? Because at the end of the day, the guy driving the garbage truck can start doing the job at age eighteen with minimal training, while the fireman/woman can start earning a living within a few months of when he/she begins training.

Medical School with pre-med and residency, plus any "extra" training for a specialty, means literally delaying starting your "adult life" by nearly a decade.

That is TEN YEARS that you don't buy a house (because your training could take you anywhere in the country), have trouble building relationships (because your training requires time commitments above and beyond 40 hours a week and could require you moving anywhere in the country that may or may not be conducive to a partner's vocation/training), DON'T begin putting money away for retirement/savings, and possibly delay child bearing due to the above mentioned issues, all while accumulating debt in excessively LARGE amounts that *must* be paid off as it accumulates annual interest.

If our garbage truck guy puts $2,000 a year away for those ten years (approximately $41 per week, starting at age 18) at an 8% rate of return, at the end of those ten years (age 28) he will have $29,389 save for retirement. If he does NOTHING ELSE (including adding to it) except leave it alone, he will have $144,794 in 20 years (age 48), and 15 years after that (age 63) he will have $478,822.

That means the LOST MONEY BY RETIREMENT (not including additional expenses incurred for the "extra education&quot is $478,822 that *must* be made up in the 35 years (not 45, like our mythical garbage man) to put our "learned healer" on an EQUAL footing financially with the guy who drives the garbage truck. (To make it up, our "learned healer" will need to put $2,400 or $200 per month away for the next 35 years -- garbage truck guy "out of pocket" was $2,000 * 10 = $20,000, but "learned healer" had to pay $2,400 * 35 = $84,000 to get the same benefit, thanks to compound interest and those "lost" ten years).

During that same period, our "learned healer" has not put equity in a house for ten years (which now has to be made up), and assuming a $200,000 debt they would like paid off within ten years at a 4% interest rate (HA!), will have to pay $2,025 *per month* to get it PAID OFF.

Physicians and other medical professionals accept that 50 hour work weeks = "part time" and I have yet to personally meet one who doesn't do it because of their personal committment to making a positive benefit to the planet to the best of their ability. (This statement also holds true for a wide variety of other professions, including teachers and other people who work for the public good.) But people who look at someone who has worked and sacrificed for a "high salary" without looking at the cost associated in finances, missed financial opportunity and family life just come off as uninformed to me.

Please note I just detailed how our "learned physician" has to put out $2,225 per month aka $26,700 yearly just to end up with schooling paid off in ten years and the same level of retirement as the garbage truck driver, not including the home equity/personal cost, which does not include anything as silly as personal living expenses, taxes or heaven forbid a family vacation, and I was using CONSERVATIVE numbers. Telling them they have to work FOR FREE because other people can't afford to pay is insulting, especially for those (unlike Jonas Salk who apparently didn't have to worry about getting his lights shut off while he was curing polio, or having his children want to attend an after-school activity like ballet class) who are already sacrificing so much to HELP OTHERS.

I highly recommend checking out the calculators at the below website if you aren't convinced of my numbers.

http://www.fool.com/calcs/calculators.htm?source=isesitlnk0000001&mrr=1.00

ON EDIT: Was in a hurry, and added the "annual" cost versus the "monthly" cost of the retirement money into the expenses - doh! Sorry!

[Egalitarian Thug]

175. Apparently I was wrong about your capacity to understand. So, let's do this the DU way,

Where to start...

You've elected to completely ignore everything I wrote and want to argue about how important doctors are and how hard it is to become one. Fine:

First off, your calculations are based on a fantasy. Now, I can easily understand how you've come come to believe in this fantasy, after all Wall Street and the political establishment it owns, along with the corporations that it represents (especially the media) have been feeding you these fantasies for, probably, your entire life. But if you can resist reacting like a Good American, and actually look into the factual numbers, you will find that a steady 8% return is excessively optimistic to the point of lunacy (Hint: The Motley Fool is an ironically, aptly named website. They make money selling you investment "advice". Find me a financial "adviser" that tells you this is not a good time to buy, and we can both look up Diogenes and let the poor guy rest), keyword; selling. Despite their efforts to hide it, if you are intrepid, you will find that right up to June/July of 2008, they were right there with Krauthammer, et al, telling all the suckers to BUY,BUY, BUY! The average return of the NYSE over the last 30 years is ~3%. If you want more information to nap by, let me know, I have reams of it.

Now, let's look at your presumption of relative value regarding professions;
At any given time the overwhelming majority of people (well over 90%) are not ill. Now, consider that in that same time frame 100% of the population is making garbage (why does everybody always pick on the garbage collectors?). Therefore, at any given moment the garbage collectors are far more important to society as a whole than even the mostest bestest doctor. If you don't believe that, you've never lived through a garbage strike.

The remainder of your argument consists of whining about lost the time and financial opportunity of the doctor while comparing him-or-her with the much abused garbage collector. The problem with your screed is that it requires you to completely ignore all of the other factors in the real world. You assume that the garbage collector earns enough to put away $2K a year every year and that that investment will return 8%, both false and ridiculously optimistic. You also assume that the garbage collector has the financial wherewithal to invest that annual $2K with some person or firm that won't churn the account to nothing. You assume that our doctor should have to pay out $200 grand to get their training, another false assumption. You then proceed to assume that the doctor has a right to pay off the assumed debt in 10 years, whereas you ignore the fact that, should your garbage collector want and manage to assume $200K (for a home loan since what on earth would a mere garbage collector ever do with $200K except buy a house with it) of debt, paying it off over 30 years is just fine.

I can go on for days pointing out the all the prejudice/ bigotry/classism on display in your non-response. If pressed, I feel perfectly safe in guessing that you are white, upper-middle-class and either a "professional" or married to one. Your sense of entitlement virtually screams from the monitor.

So once again I'll repeat, since reading what was written was too much effort, Everybody deserves to be paid for their contributions, but nobody is entitled to get rich at the expense of everybody else. People that have the desire and capacity to become health care professionals are the only people that should enter the health care field, people that simply want to get rich should not be allowed within 10 miles of a hospital except as a patient.

[IdaBriggs]

177. We will simply have to agree that we both think the other is

(politely) not that bright. I am a white middle aged professional (computers), and bluntly middle (lower middle) class. I believe my mythical garbage man can put away $40 per week, since my sister the waitress managed to do it, and was able to find (free) investment advice at our local credit union while making less than $18K a year while supporting her son as a single parent who received Zero Assistance from Anyone. It can be done if one chooses to do so. Her retirement portfolio is doing well, despite market corrections over the last 15 years.

There are other tools out there if you choose to use them, and the calculators allow you to put in your own assumptions if you do not like my (conservative/reality based) ones.

Math is hard. It is always good to be reminded that not everyone can do it. Thank you for being today's shining example!

[Egalitarian Thug]

178. It's not the math, it's your erroneous assumptions behind he math.

I find it interesting that in both replies you've chosen to ignore what was written and attack a nonexistent argument. BTW, the degree I eventually decided to take is in computer science, so I'm fairly familiar with advanced mathematics and how, shall we say focused, many in the field are.

I'm also not at all surprised that you also don't seem to be able to understand the difference between anecdote and fact, nor have the wherewithal to find them.

Yay for the DU way! Why discuss when you can ignore and insult!

[IdaBriggs]

179. We both think the other person's assumptions

are "mistaken" and I believe the flirting with insults began with your comments. I am familiar with the term "anecdote" but while you seem to think it means "exception to the rule (because ignorance is easier)" in the example I provided I was offering "proof" that sound financial advise is not beyond the means of anyone with access to a credit union, and "low income earners" who practice good money management skills exist.

To be fair, my sister is amazing; we made her watch "The Wealthy Barber" when she was young, and she has done an excellent job of applying those principals to her financial dealings. PBS and Free - oops! There I go being all hoity-toity again! Dare I also confess I read books? No! Especially when so many are FORBIDDEN access to such secrets - except they aren't - best I stop replying! I fear my lack of interest in American Idol will be exposed! Free information from libraries and the Internet about financial planning and math - oh my! I am SUCH a blue stocking!

Can't really do because it is true.

Free advice as an established computer (top tier) developer - when doing system design, you need to understand not just what you want at the end (free health care for everyone), but also the inputs and constraints as well as the calculations to get there. When you are ready to discuss these things, we can start working up specifications. Until you can hold a couple of hundred tables with the required relationships in mind, you will be limited in your skill set because you don't know how to address problems, especially if you are busy pretending they don't exist. Good luck.

[Egalitarian Thug]

180. If I had made any assumptions you might be right, but I haven't and you're not.

You've taken this past the point of any relevance to anything except whatever scenarios swirl around inside your own mind. Perhaps they collided with all those tables you are keeping in your "top tier" mind?


So to review (and kick this thread one more time):
The OP asked if it was ethical for a doctor to refuse treatment to a medicare patient. KT2000 replies that a church had started a clinic because the practice had become so common, to which MrSlayer implied that making money was the primary motivation for doctors.

antigone382 related a story about the doctor they know that has found great relief practicing in Canada because (s)he can focus on treating patients without worrying about their ability to pay, to which I replied that people should go into medicine to practice medicine, not for the money.

(Here's where it takes a turn toward the bizarre)
You jump in with a non sequitur regarding mechanics doing their job for pay and go off about studying for 23 YEARS!!1! and THEY HAVE TO BE COMPENSATED FOR ALL THE TIME THEY'VE LOST

I, foolishly thinking that perhaps you simply misunderstood what was being said, replied that doctors in Socialist countries are indeed compensated and live very nice, fulfilling lives, they just generally don't become super rich. I go on to opine that people that want to get rich should pick a field other than medicine and asked you to consider a scenario.

You ignored what was written as well as the question, to go off on your bizarre rant about how unfortunate the doctor is compared to the "lowly" garbage collector and proceed to build some fantastic monetary scenario using invalid numbers plugged into a compound interest formula you found on an investment website.

It was when you went off on how Jonas Salk was so lucky that he didn't have to worry about having his lights turned off or sending his child to ballet classes, that I should have realized that there was no rational thought going on here and just ignored you. But no, you were writing in complete sentences and I was just sure that you had somehow got the wrong idea along the way and decided to answer in kind.

The mistake was mine. I'm old enough to know better.

On the upside, after leaving the field and having encountered a contemporary "top tier" developer I have a much clearer understanding of why every database I encounter now returns invalid results. GIGO and the Peter Principle rule America!

[Niceguy1]

3. if the Medicare

Reimbursement rates are at or below the Dr's costs to provide the service then it is perfectly ethical to refuse service. The Dr should not be forced to subsidize such services.

[1337kr3w]

4. I agree

I agree. Just like if you have paid med insurance, certain insurances won't be covered by certain doctors if you don't fall within the plans coverage. I think it's just as fair for people on medicare to have the same equality, they just happen to have insurance because they can't afford it. I see nothing wrong with this practice, yes it may be annoying that you can only find 1 out of hundred in your area that will take the insurance but at least you have insurance, there are people who don't have medicare that need it so I'd consider myself lucky.

[Gravitycollapse]

5. Why would doctors costs to provide service differ?

Most diagnostics are done out of house and the advising is a service rendered. The costs should be the same.

[Niceguy1]

6. overhead costs vary and

Lab costs vary from lab to lab. And Medicare reimbursement rates have-not kept up with inflation

[sendero]

9. My doctor...

... with whom I've had numerous long discussions about this, claims that the Medicare reimbursement will not pay his costs. To be fair, he claims that some regular insurance contracts won't either. The "health" insurance companies make big payouts to surgeons, anasthesiologists, various other specialists, but they put a serious squeeze on the family physician.

Back in the 90s I had a really good doctor. On a visit, he told me that I would probably not be able to see him any more as he was going to have to drop his contract with a well-known insurance co (Ae***) because they had reduced his office visit reimbursement to something like $28 which he said didn't even come close to covering his costs. He said that when he told them he was going to forego the contract, they laughed and told him that their insureds made up 25% of his practice and that he had no choice.

He got a small story on the local TV news. He did drop them, and he referred me to another Dr. who I am still seeing. He is still practicing.

[customerserviceguy]

10. I don't think so

Is it unethical for a doctor to cost-shift from Medicaid and Medicare patients to uninsured patients, because they can't get decent reimbursements from the preferred provider networks that serve their insured patients? Because that's what most of them do. Somebody ends up holding the bag, if it's not the doctor, then it's some other group of patients or their insurers, if they have one.

Here's a solution to the Medicare/Medicaid problem: A government insurance company providing automatic, free coverage for malpractice insurance for Medicare and Medicaid patients. If a doctor treated 100% from those groups, he/she would have zero out of pocket premiums for that ruinously expensive insurance. On the other hand, I'd have those patients go through arbitration boards and not through the courts, no sense in making lawyers rich. Also, it would be publically known which patients were apt to be frequent users of the boards, and what the outcomes were for the charged doctors. Full transparency on both sides would take a lot of the guesswork out of the process as it currently exists.

[MattBaggins]

20. Arbitration boards are there just to protect the industries that will own them

I kind of believe I have a right to a lawyer and access the court systems.

[customerserviceguy]

101. In many cases, yes

We can enact safeguards to that, perhaps by making these boards accountable to the public in some ways.

You like lawyers, I despise the long, drawn out, expensive, uncertain, and capricious nature of the tort system. In the end, when malpractice is truly deemed to have taken place, it's more often than not accompanied by gag orders that protect the guilty. One of the key differences between the US system of medical practice and the rest of the world is not only the cost, but the extreme fear of litigation that hovers over absolutely everything.

It adds billions of dollars to what we ultimately pay for medical care in this country, that's why I'd like to see an end to it. Starting with people who simply cannot afford their own medical care is a good place to begin.

[OneGrassRoot]

11. Physicians for a National Health Program

Excellent site, excellent info.

http://www.pnhp.org/facts/single-payer-faq#income

What will happen to physician incomes?

On the basis of the Canadian experience under national health insurance, we expect that average physician incomes should change little. However, the income disparity between specialties is likely to shrink.

The increase in patient visits when financial barriers fall under a single-payer system will be offset by resources freed up by a drastic reduction in administrative overhead and physicians’ paperwork. Billing would involve imprinting the patient’s national health program card on a charge slip, checking a box to indicate the complexity of the procedure or service, and sending the slip (or a computer record) to the physician-payment board.

Under single payer, won't physician incomes go down?

Not necessarily. Canadian physicians have done well under their single payer system - as documented in a recent, careful study. In addition, streamlined billing under single payer would save US doctors vast amounts in overhead, and free up additional physician time to see a few more patients. Hence, even if doctors' gross incomes declined slightly (a questionable assumption if they're freed up from insurance paperwork and able to devote more time to patient care) physicians' average take home incomes wouldn't change under single payer. Of course, some doctors' incomes would go down - e.g. those who currently enjoy a particularly rich payer mix. On the other hand, some would see an increase - e.g. those currently caring for many Medicaid or uninsured patients.

- answer contributed by Dr. Steffie Woolhandler

[no_hypocrisy]

12. Before my physician father retired from practice,

I'd estimate that 80 percent of his patients were Medicare and he chose to treat the elderly.

[littlewolf]

13. I have Tricare standard

and there is no problem because we have to make up the difference
between what the insurance pays and the bill. which usually isn't too bad.
however some of my friends have Tricare prime. and fewer Dr.'s. are taking
it because of the reimbursements are so low. Tricare has been
lower payments for several years. we do not go to the Dr. much so
it really doesn't effect us alot.

[Recursion]

14. Refuse urgent care when on hand? Yes. As a general business policy? No.

Doctors are always going to have their market niche that they want to fill.

Public Health researchers are doctors; they don't see any Medicare patients...

[Yo_Mama]

15. No

Doctors (who are still in private practice, which is becoming less and less common) have to pay their bills. For most of them, limiting the number of Medicare/Medicaid patients is necessary to be able to pay their bills and their employees.

It's not that they make LESS money on many of these patients - many of these patients cost them money to treat.

If you want to provide high-quality medical care, the 5 minute visit model is out. If you have too many of these patients in your practice, you have to adopt the 5 minute visit model to cover your costs.

Provisions of the ACA involve upping Medicaid reimbursements, which should help the situation somewhat.

[bemildred]

16. If it is because of the money, then yes, it is. nt

[JaneyVee]

17. Living in NYC I always find these OPs strange because Medicare/aid is accepted almost everywhere

Doctors would actually make less money by refusing medicare/medicaid patients.

[HockeyMom]

65. I have seen it on Long Island

Pay me up front, and then get your money back from Medicare, but they also refused to take HMO. Only PPO. "Pay the difference" I was told by the same. No, I will find somebody else. Goodbye.

[MiniMe]

18. My mother's doctor charges something like $200/year to accept Medicare

She pays it with no problem. I think a lot of docs are doing things like that now.

[LanternWaste]

19. I'dI'd imagine it is quite unethical for a doctor, or anyone else to imply...

I'd imagine it is quite unethical for a doctor, or anyone else to imply, "my profits are worth more than your health-care".

That being one of many reasons I believe that the medical industry (amongst others) should not be part and parcel of the free market.

[cbayer]

21. No, it's not.

If reimbursement rates do not cover expenses, why should a doctor have any ethical responsibility to take new patients with inadequate coverage.

[LanternWaste]

23. That's a wonderfully accurate example of Burke's truism

That's a wonderfully accurate example of Burke's truism, "...when good people do nothing"

[cbayer]

33. Good people are trying to do something all the time.

The fact is that primary care physicians, who are on the front lines, can not keep their doors open with most medicaid reimbursement. Medicare is generally, but not always, adequate.

What do you think they should do?

[WinniSkipper]

79. Do you work to lose money? nt

[bemildred]

31. Because he/she has a government licensed and enforced monopoly to practice his trade, that's why. nt

[cbayer]

32. S/he also has an obligation to pay the employees, rent, taxes, malpractice insurance,

supplies, etc., etc.

If the government reimbursement will not cover the cost of doing the job, should the individual physician just do it as charity? Not pay their employees?

[bemildred]

43. S/He has many obligations, so what? So do we all.

I'll sympathize with he/r when s/he sympathizes with patients who are sick. It is never seemly to have people who are well off whining about the demands placed on them as a consequence of their privileged position.

[cbayer]

52. So would you take a job where you didn't get paid?

This is a reality for many primary care, front line physicians.

Physicians give away a lot of care. Many of the patients that come to the emergency room can not every pay a cent and they are cared for. Patients who are hospitalized often use up their benefits or have no insurance and physicians treat them for free all the time.

In order to make this possible, many have found themselves unable to take on new patients who have inadequate coverage. FWIW, medicaid is almost always inadequate.

Less and less people are applying to medical school and those that go are coming out with higher and higher debt. They also want to specialize in areas where they know the reimbursement will be good and the time demands/risks lower. When the ACC kicks in, we will see a primary care physician shortage that is going to be a full blown crisis.

Blaming the front line providers is wrong. The blame lies squarely on the shoulders of those that set the reimbursement schedules.

[Gravitycollapse]

54. "When the ACC kicks in, we will see a primary care physician shortage..." More speculation?

[cbayer]

55. Not speculative at all.

[Gravitycollapse]

57. Soo...what are your sources?

[cbayer]

60. Just google primary care physician shortage.

It will give you more information than you will know what to do with.

[Gravitycollapse]

62. I didn't ask Google for its sources. I asked you.

[cbayer]

64. I don't play this game. Nice talking to you.

[Gravitycollapse]

67. Here, I did your job for you...

http://www.kevinmd.com/blog/2013/03/primary-care-physician-shortage-overblown.html

[cbayer]

69. Lol, you found the single article on the entire first search page that takes this position.

[Gravitycollapse]

75. The issue here is that it would actually be better to spread medicaid patients over more doctors.

Thus negating the need for special clinics. It's kind of like the issue of high risk pool insurance. We wouldn't need it if we could simply evenly spread "high risk" patients across the insurance industry.

So when doctors turn away medicaid and medicare patients, they're making it all worse. And they're knowingly pawning off poor patients onto overworked and underpaid doctors at underfunded clinics. Instead, they should be advocating to congress for greater medicaid and medicare funding.

[cbayer]

167. Physicians relentless advocate for better funding.

And the good news is that more and more physicians are supporting a single payer, universal care system.

But in the meantime, the system really sucks.

[guardian]

113. There are numerous sources

both in government and in the medical industry. There WILL be a shortage or primary care physicians. People will wait longer to see a doctor. More and more services will be shifted to mid-level providers (i.e., nurse practitioners and physician assistants). More people will need a 'referral' from the mid-level to schedule an appointment with a physician.

You will also see more and more foreign trained doctors filling the gaps. So if you like calling customer service in India you will love the future of medicine.

[Gravitycollapse]

115. Show me where it demonstrates that the new healthcare laws will cause physician shortages.

[guardian]

117. Frankly

I don't think ANYTHING could convince you otherwise. Just wait a year or two.

[Gravitycollapse]

118. You can't accuse me of being unconvinced when you do not try to convince me.

Show some proof. Since when was showing proof considered asking too much?

[guardian]

121. A few of literally tens of thousands of similar articles

http://medicaleconomics.modernmedicine.com/news/affordable-care-act-brings-influx-patients

http://healthaffairs.org/blog/2012/08/02/the-big-shortage-rethinking-the-need-for-more-primary-care-doctors/

http://medicaleconomics.modernmedicine.com/news/how-affordable-care-act-will-affect-physician-shortage-primary-care

http://medicaleconomics.modernmedicine.com/medical-economics/news/modernmedicine/modern-medicine-feature-articles/senate-report-highlights-prim

http://www.managedcaremag.com/archives/0706/0706.shortage.html

[Gravitycollapse]

126. Was that really so difficult?

[guardian]

127. are you convinced yet? nt

[Gravitycollapse]

129. Yes I am. I did not ask for sources as a joke.

I do not like people making such claims without sourcing it.

If you are saying that the new healthcare law is going to cause physician shortages, you need to provide evidence. That goes for any claim really.

[guardian]

131. my apologies

I perceived your request for sources as something of a snark. To me it was obvious. But then I work around the medical industry so I'm used to everyone I meet being aware of these issues. Maybe I'm just tired? It's been a long day.

[bemildred]

58. They can quit, I don't care.

But if they work under a public license and monopoly, then they will serve the public and have public obligations. And that includes serving patients who cannot pay full fare, and otherwise contributing to the system and helping make it work for everybody.

And yeah, I've done all sorts of things I never got paid for. So what?

[cbayer]

63. They do quit. Retirement rates are higher and retirement ages lower.

It's not a public license. It's a professional license. It costs thousands of dollars and is in place to protect the quality of care, not to insure that all of the public has care. There are absolutely no public obligations, just professional ones that require that they meet certain standards of care.

It's not the physicians obligation to provide what you describe. It is the governments.

And it's not volunteer work. It's a job.

[bemildred]

66. Good. Get the deadwood out of the way.

it is a public license, it comes from the government, and the government enforces it. You cannot be a doctor without a government license. it is whatever the government says it is.

[cbayer]

72. It doesn't come from the government. It comes from the state medical boards and is enforced

by the state medical boards.

Your information is incorrect.

[Gravitycollapse]

76. Are state medical boards not part of the government?

[cbayer]

89. No, they are not. They are independent non-profit agencies.

[Gravitycollapse]

90. Yes, they are actually. ""The Medical Board of California is a state government agency..."

"The Medical Board of California is a state government agency which licenses and disciplines."

http://www.mbc.ca.gov/board/role.html

[cbayer]

164. I stand corrected.

[bemildred]

77. The state is the government?

The state medical boards are arms of the government? They also operate as government sanctioned monopolies, but not for profit one assumes. Just try to start your own state medical board and see what happens.

You are stuck Bucko, however you follow it back, you always come back to the government's exclusive right to use force as the thing which creates and structures the entire health care system, top to bottom, and enforces it, the legal system to sue you and enforce your bills, the FDA, HHS, state medical agencies of all stripes, public educational institutions, and so on.

[guardian]

122. Yeah that's smart.

Have doctors quit when there is a massive shortage coming.

Just how much money do you think a physician should take home every year?

[bemildred]

151. The problem is that I have no reason to care.

Whether they are in sufficient supply or not, they are no good to me. Like many Americans now, one of my main goals in life is to never have anything to do with our "health care" system, both to avoid bankruptcy and to avoid iatrogenic disease and misdiagnoses, etc., not to mention not being treated like barnyard animals being herded around in a feedlot.

[guardian]

154. How very nice of you

not to care if sick poor people have access to healthcare. A sentiment that would make Rush Limbaugh proud.

[bemildred]

155. Being snotty about it won't change my attitude.

Doctors who won't see the poor don't seem to give a shit about access for the poor either, eh?

[quakerboy]

85. A question

How many poor MD's do you know?

[cbayer]

165. Poor? None. Took no salary for periods of time? Forced to spend less time with each patient?

Reduced staff? Plenty. And unhappy, can't wait to get out of medicine? Lots and lots.

[WinniSkipper]

80. I know a doctor who...

...had gone approximately 2 years without a paycheck. Borrowed money from his parents for his kids college.

Why? Medicare does not reimburse enough on the chemo drugs he provides. He took no salary to keep his nurses employed, and his patients healthy .

You seem pretty ignorant on the issue. The issue is HOSPITALS. They are driving your country doctors/GPs/etc out of business. They don't like competition. So hospitals have powerful lobbies, and THEY get the good discounts on the drugs.

[bemildred]

82. Do provide more anecdotes to support your views, Mr. Science.

Anybody that goes two years without getting paid has bigger problems than I can solve. The fact that his business plan does not work is unfortunate, to be sure. He should find a job that pays him regularly.

[WinniSkipper]

84. It's my cousin

Oncologist in Ohio. A practice with three other doctors.

Why does someone, a doctor, who goes without a salary have bigger problems than you can solve? Weren't you just complaining that they SHOULD be that considerate?

Why should he find another job. He's not in medicine for the money. He's in it for the patients

You just seem to have an incorrect attitude about many in the medical profession.

[bemildred]

87. I'm not saying you are lying, I'm saying it's anecdotal evidence.

And hence means zippo, nothing. I can tell lots of anecdotes too.

I quite agree that our health care system is broken, and that it is so broken now that it even screws doctors too. What I don't agree with is the idea that the way to fix it is to make it worse, by serving only the well-off, and allowing the greed-heads to take it over completely. Before I will agree to that, I would can the whole system and start over: public health care for all, public medical education for all, etc., regulation top-to-bottom so that everybody gets paid and everybody gets served.

[Gravitycollapse]

49. Is payment lower than cost an actual problem?

[cbayer]

50. I'm not clear on what you are asking here.

[Gravitycollapse]

51. Does Medicare and Medicaid offer such low payments that doctors make no money?

Or is this speculation? Because I find it hard to believe that those programs would offer payments that did not cover costs.

[cbayer]

53. Absolutely true for Medicaid. It often costs primary care doctors money to care for these patients.

Medicare tends to be better, but many PCP's are forced to see larger and larger numbers of patients to make ends meet. This leads to poor care and the need to start limited one's practice.

What do you suggest they do?

[bemildred]

61. Quit, Go on strike. We look forward to it. nt

[cbayer]

68. We who? You aren't going to look forward to it if you need medical care while it's happening.

BTW, doctor's in this country can not collectively bargain, unionize or go on strike. This makes it very, very difficult for them to protest in any effective way as a group.

[bemildred]

70. All of us who think it is unethical for MDs to turn people away because of "cost".

I want all those "Doctors" gone.

[cbayer]

74. Well, good luck with finding one.

[bemildred]

78. I'm on Medicare, I already can't find one.

That is why I don't care about their whining.

[cbayer]

166. I would suggest that that is exactly why you should care about their whining.

[bemildred]

172. I'm busy today, and I'd like to continue this conversation

It seems like a worthwhile discussion: what should we do? And I am curious what you think about it, assuming you were in God Mode..

So consider this just a marker, I'll pick it up tomorrow.

[cbayer]

173. It's been a good conversation.

If I were in god mode, I would go for a nationalized system where all physicians were employed by a central agency. Reimbursement would be fair and equal for all patients. Specialists would make a lot less, primary care a lot more. Physicians would be incentivized for keeping people well and not for how many they could squeeze into a day. Education would be a reasonable cost. Physicians would have reasonable schedules and responsibilities. Non-physician professionals, like physicians assistant and advance practice nurses would be able to do a lot more front line work.

I am hopeful that we will get there. IMO, the ACA kicked open a door that I thought I would never see open even a crack.

In the meantime, healthcare professionals, patients and advocacy groups would work together to identify where we need the most attention and stop attacking each other.

Simple!!

Have a great day.

[bemildred]

174. Thank you, I'll chew that over and try to say something constructive. nt

[bemildred]

181. I think our God Mode designs pretty much coincide.

So to the extent we disagree, we must disagree about how to get there, or perhaps how to start.

But I would wager from what I read there that we would also agree there. So maybe it's just an insider/outsider kind of thing.

But it also suggests that you are right that bickering serves little purpose.

I think we have to start with the money, make it not-for-profit top to bottom, you cannot serve both God and Mammon. Within that context, you want to attract the best and keep them motivated, so you treat them very well. I know that it approaches being heresy in America, but not every human activity is fit for trade. Medicine, or at least modern medicine, appears to me to be one of them.

[cbayer]

182. I think we are on the same page.

There is so much wrong at this point and it's too easy to try to scape goat one party or another, but the profiteers are the ones who most deserve scrutiny.

Physicians are currently reimbursed in ways that make no sense at all. There are aspects of the ACC that are addressing that and starting to reimburse for providing effective and preventive care, instead of just by volume. That's an excellent start, imo. I completely agree with you that medicine should not be treated like other services, but that's the way it has been and many, many physicians are disillusioned and just want to get out at this point.

Anyway, great to talk to you. I hope to see you around again!

[guardian]

116. When you agree to work a 40 hour job for free

Last edited Thu Mar 21, 2013, 12:38 AM - Edit history (1)

then you can complain. Doctors have to pay mortgage/rent, buy food, buy clothing, etc. No one is giving them a discount. So save your rants for the other denizens of the hypocrite hotel.

[bemildred]

150. I can complain any time I want to. You don't decide that.

Your self-serving arguments aren't worth a bucket of warm spit. Whiney self-pity is most inappropriate for someone who has the good fortune to become a MD.

[BainsBane]

132. I thought they were required to have 10% of the practice

minimum as Medicare. Maybe that's just in my state.

[cbayer]

163. That has to be a state based rule. In most states, you wouldn't even be

required to get Medicare number if you didn't want it.

[NaturalHigh]

24. Same as many other questions of ethics...

In a legal or professionally ethical sense, no it's not unethical. Is it morally ethical (sorry, I don't know a better way to express it), probably not.

I don't have a better answer. I do know that my doctor is currently not taking any new medicaid patients because he's already so busy.

[liberal_at_heart]

25. I think it is. Medicare and Medicaid will only pay out so much. That is what keeps cost down.

So doctors who accept Medicare and Medicaid cannot charge whatever they want. I read an article recently that said that is the biggest problems with healthcare right now. Doctors and hospitals can charge whatever they want and there is no cap, no competition, no accountability for how much they charge.

[MFM008]

26. My old apartments did worse than a doctor.

My housing complex that I had been living for 23 years just 0.45 miles from the family home, threw me out because I get a housing subsidy. Im older, handicapped and had a 3rd floor 2 bedroom. None of that mattered, I downscaled to a one bedroom across town. I know im lucky to get anything but I cant explain the amount of stress this caused. I even had to put an older pet who was ill to sleep sooner because there was a $300.00 deposit on each pet I had 2. No there was no help, my move cost us $$$1000.00. 23 years with no problems, always payed rent on time. Hows that for ethics.

[Manifestor_of_Light]

27. I tried to see a doctor that does not take CASH, believe it or not.

The receptionist gave me some bullshit line about how they only took insurance. I said if my green money wasn't good enough, I'd go elsewhere. I figured the guy is a right wing shithead.

[Gravitycollapse]

28. I'm pretty sure it's illegal to decline cash payment.

[Manifestor_of_Light]

34. Don't think it's slowed him down.

I took my business elsewhere. He's probably a TeaBagger.

[Honeycombe8]

42. I don't think so. They have a right to determine method of payment.

If they accept cash, then they have to make a run to the bank to deposit, come up with a security system so they're not robbed on the way to the bank, have petty cash to give change, etc. It's a hassle, I guess.

Places used to reject plastic, now it's the other way around.

[Gravitycollapse]

47. Hmmm...it appears federal tender law agrees with you.

I was always under the impression that businesses were legally obligated to accept actual cash payment.

http://definitions.uslegal.com/l/legal-tender/

[Sgent]

103. The bigger issue

is continuity of care.

Once a doctor accepts you as a patient, they are responsible for your care until you can ethically be discharged. Discharge is only ethical once an acute issues is resolved, your discharged to another provider, or in some cases after 14-30 days notice.

If you come in to see a doctor about an infection, and pay cash, he may get paid for that visit -- but not for your week long hospitalization, etc.

[bluestate10]

29. Take out an ad in your local newspapers, name the doctors if that is possible. nt

[bluestate10]

35. Or talk to the doctors that do take Medicare and Medicaid and see whether they are

ok with their practices being identified as good businesses. I am proud to say that my doctor treats everyone.

[Sadiedog]

30. I have asked myself this question many times.

Part of my job is to help people on medicaid find services. It is difficult and many Dr's. will not except adults but will see children. But finding dental care is next to impossible, I have to send people 60 miles away to get dental treatment, it is heartbreaking. The sad thing to me though is the shortsightedness of some as then many will instead go to the emergency room (for both dental and medical) which costs sooo much more.

[Llewlladdwr]

40. Indeed.

Doctors should be forced to treat people for free. The right to healthcare trumps the right to profit.

[Gravitycollapse]

41. Doctors should be paid. We all have to make a living.

But they should be forced to accept plans like Medicare and Medicaid.

[Honeycombe8]

45. Then there won't be any doctors. Who would pay half a million dollars...

to go through med school, if they wouldn't get paid well enough to pay that off?

How would they pay their mortgages, send their kids to college, enjoy a nice lifestyle reflecting the years of study and hard work and financial debt they took on?

None of us works for free, unless we volunteer on a limited basis in our free time.

[WinkyDink]

71. Right. American doctors are just scraping by.

[Honeycombe8]

138. They earn their $, though. It's not easy being a doctor.

You have to get a bachelor's, then med. school, then residency, then internship. During residency and internship, you basically don't have a life, working without sleep or catching a few winks at the hospital and not going home. That lasts for years. It also costs a fortune. And it's hard...you have to have brains, and even then, you have to study a lot. In addition to that, if you become a surgeon, you have to have artistic flair, and go through MORE residency or internship.

Then you are required to do continuing education. And you have to pay to maintain your license and belong to some medical association.

They also have a business. They have nurses and bookkeepers and other staff to pay the salaries and benefits of. Do you think the staffers should be paid well and get benefits? They can't be, unless the doctor has paying patients.

No one would go through all that to get paid what an office worker does, given that the office worker didn't have to do any of that.

So it would be nice if they would accept a FEW Medicaid or Medicare patients. Some do. But it's understandable if they want to earn money to pay their debts and live a nice lifestyle. They earn it.

[guardian]

130. Don't forget that doctors

1. Are smart and could do many other things that make a good living (lawyer, engineer, professor, entrepreneur, etc.).

2. Doctors work their ass off in school. How many people are willing to stay in school until age 35 or 40? And this is not easy sociology major type stuff with beer bongs on nights and weekend. They are studying their ass off.

3. Average doctor spends $250,000 to $300,000 for their education and starts life at age forty with $300K in debt.

[Honeycombe8]

139. That's true. I have no problem with people making money, if they earn it honestly. I wish they would

set aside a bit of their practice to aid the poor, and some do. But I understand the money thing. I work for money, too, and I don't give away my services. (But maybe I will later, when I semi-retire. I can't afford to now. I'm in the legal field, so I could volunteer at a pro bono clinic.)

[WinkyDink]

44. Yes.

[Honeycombe8]

46. No. They have a right to determine their rates & the paperwork

they'll deal with.

They are small business owners. They're in business to make money, although it's healthcare. If we had a national system, this wouldn't be a problem, I guess, but we don't.

[Gravitycollapse]

48. I did not ask if it was legal. I asked if it was ethical.

[Honeycombe8]

56. And I answered. No. They have a right to determine their rates.

I did not say "legal" right. They have a right, in every sense of the word.

[Gravitycollapse]

59. So they have an ethical right to deny treatment because they want more money.

That's essentially what you're saying, right?

So if they want that new Mercedes, it's okay for them to avoid medicaid patients?

[slipslidingaway]

104. You are blaming the wrong people ...

for the most it is not the actual providers but our HC system that is dysfunctional. From the very beginning the actual providers have a large debts and expenses that are unique in our for profit system.
I always find it interesting when people blame the people trying to function in a dysfunctional system and not the system itself.
The Dems had a perfect opportunity to promote a more equitable HC system and they blew it big time, not once but twice, both Clinton and Obama made serious errors in not allowing a full debate on HC.

And you're blaming the doctors!

[Gravitycollapse]

107. I blame the system and the doctors.

There are doctors who treat the poor and doctors who do not. Not every doctor is an angel.

[slipslidingaway]

134. I blame the system more than the docs...

if they can most will help and that is why many entered the field taking on large debts at a young age, but they have to operate within our For Profit system.

I've met very few of my daughter's friends who entered the field for the money.

Do some become corrupted by the system... yes they do. Most had the capacity to enter the world of high finance, but they chose otherwise and that surely would have required less debt.

Yes, hardly anyone is an angel and that translates to many fields. But do not blame our dysfunctional HC system solely on the providers without any mention of those who profit from our system and the politicians who keep them in power and do not have the knowledge or ability to actually provide the care.

[Honeycombe8]

140. Yes. That's their profession. I don't work for free, either. They have staff to pay for...

and business equipment and utilities, and a huge loan for med school to pay off. And licensing fees, and continuing education. On top of that, they want to live a nice lifestyle, and I don't blame them for that. It's very difficult to become a doctor. And very expensive. And it takes years.

It's the govt's fault, not theirs, that this is the system we have.

[WinkyDink]

73. Best hope you don't live to rue your words.

[Honeycombe8]

141. It wouldn't change anything. It's not unethical not to work for free. I don't work for free, either.

You're confusing health care with job. It's health care, which I believe is a right. But legally it's not a right in this country. So we have people who provide that service, and to them, it's their job/profession.

It's not nice of them not to volunteer their services, since it's such an important service. But it's not unethical, which was the question.

You're blaming the service provider, rather than the system. I blame the system.

The provider also provides wages and benefits to nurses, bookkeepers, leases and buys equipment, pays utilities and rent for the office, insurance. It's expensive to run a health care office.

[cherokeeprogressive]

81. Is it ethical for someone who's intelligent and rich to go into Engineering rather than Medicine?

Or Law? Or Architecture? Or any other profession for that matter?

I choose not to treat Medicaid and Medicare patients. Am I unethical?

What do you do for a living? If it's not medicine, isn't it fucked up and greedy, if not a little unethical?

[Gravitycollapse]

83. Yes I believe it is unethical for you to not treat medicaid and medicare patients.

This is not a discussion of the ethics of choosing one field over another. The discussion is about how one conducts oneself once a field is chosen.

If you choose not to treat medicaid and medicare patients because you want to make more money, you are choosing to make some extra money off the suffering of others.

[cherokeeprogressive]

86. Be glad I don't treat Medicaid and Medicare patients. Be very glad.

I drive a trash truck. Recycle truck actually.

[Gravitycollapse]

88. So you were falsely leading me to believe you were a doctor...

to prove an already unethical point.

[cherokeeprogressive]

91. Beggin' your pardon... I didn't falsely lead you to anything at all.

I made a statement that was 100% factual in any language and by any interpretation.

Don't blame me for your inference.

I don't believe if one chooses to become a Doctor, subsequent choices are made for him/her.

[Gravitycollapse]

94. You lead everyone to believe you were a doctor denying treatment.

Don't blame me for finding your intentionally misleading statements obnoxious, distracting and counterproductive.

[southernyankeebelle]

95. well I am happy to know you are a trash truck driver. Your job is just as important as a doctor.

You may not make that kind of money a doctor does but your job is important. If you and the people who work in your field didn't pick up garbage we all would be in a lot of trouble. So I say thank you for doing your job. People need some prospective.

I will say in a doctor's defense is they have a lot of overhead they have to pay for when you think about it. New equipment can cost a lot of money. Employee payroll. Insurance coverage in case they get sued is very high.

I have a sister that is a dentist. She had a serious illness and had to be out for 8 weeks after surgery. She worried because she has employees and the business slowed down some. She was able to find a dentist who wanted to work part time and a couple of other friends helped out. She also does a lot of pro bono work. She also goes once a yr to the Dominican Republic where they work on the poor's teeth. So it also took her 10 yrs to pay her student loan back. It's a lot of responsibility but she wouldn't have it any other way.

[Honeycombe8]

143. Is it unethical for a trash truck driver not to work for free at least some of the time?

If he's providing a valuable service, should he be required to work for free at least some of the time, ethically speaking?

[southernyankeebelle]

152. Why? He is a wage earner and didn't go to college. He didn't take a Hippocratic oath yet if your

garbage isn't picked up it could be a health issue, right? A doctor also does a valuable service and he signed a Hippocratic Oath. No one is telling him he has to do charity work. I am sure he can also use that as a tax credit when he does use his work as charity. You are mixing apples and oranges. I am not saying that a doctor isn't more important than the trash pick people but you have to admit if they didn't do their job the health issue can be serious.

[cherokeeprogressive]

156. I have a Bachelors in Vocational Education from Long Beach State. n/t

[southernyankeebelle]

157. That is wonderful. What's your point? Just wondering. I'm not trying to down people who have a

college education. I was just talking about the value of both being a doctor and a trash trucks and the people who do that job in that it would be a health issue. That's all.

[X_Digger]

92. If medicaid and medicare don't cover the treatment for such patients, then no, it's not unethical.

Is it unethical for you to be asked to work without a paycheck at certain times?

[RedCappedBandit]

93. Doctor's offices should have nothing to do with money.

But then, our entire health care system is the joking stock of the developed world.

[slipslidingaway]

97. Exactly, their hand is forced, especially with the cost ....

of med school and it is not getting any better

[slipslidingaway]

96. No they have loans to pay ...

and living expenses as well.
How do you expect the docs to for pay expenses?
We partially pay for some of our daughters expenses, a current resident with large loans, while trying to juggle the out of pocket expenses after my husband's bone marrow transplant for acute leukemia.
A roof over your head is not free, she still comes home to do laundry as it is "free."
Our health care system has a major problem, but unfortunately the Dems took any discussion of a national HC system off the table during the last debate.
Maybe you should look to the politicians who bow to the profits of the HC system, who do not provide any healing services, and that includes both Repubs and Dems.

[jazzimov]

100. The Hippocratic Oath makes it unethical.

However,

In a 1989 survey of 126 US medical schools, only three reported usage of the original oath, while thirty-three used the Declaration of Geneva, sixty-seven used a modified Hippocratic oath, four used the Oath of Maimonides, one used a covenant, eight used another oath, one used an unknown oath, and two did not use any kind of oath. Seven medical schools did not reply to the survey.

http://en.wikipedia.org/wiki/Hippocratic_Oath

[Honeycombe8]

144. No, it doesn't. The oath says that the medicine they practice must be done ethically and honestly.

It doesn't say that they must not get paid for it, in order to be considered ethically and honestly.

[Lady Freedom Returns]

105. I think it is. What ever happen to "First do no harm"?

The poor needs medical. Many need more than one of those walk-in clinics. That is why they have Medicaid and Medicare. Yet greed is talking in multiple directions and the poor get screwed in the end again!

[slipslidingaway]

119. Exactly why we need a not for profit system, but the Dems blocked any discussion ...

under Clinton and then under Obama.

The keynote speaker at my daughter's graduation from med school spoke of access to all which I was very happy to hear. We had special box seats as my husband's ANC was close to zero after his recent bone marrow transplant, but I was surprised at the tone of the speaker and how everyone deserved a chance.

All of that being said there are bills that need to be paid, is anyone willing to work for free?

Don't get me wrong there are people who are only interested in profit, but there are many more who get caught up in the for profit system and have bills to pay.

W need to look at the system, not necessarily the individuals.

[Honeycombe8]

146. "do no harm" to those you treat.

It doesn't say "do no harm, and do it for free to anyone who demands treatment."

[DBoon]

106. Is it unethical for grocery stores to refuse customers paying with food stamps?

Only if your sense of ethics proscribes gratuitous cruelty towards people with few resources.

[Gravitycollapse]

108. Yes, it is unethical to refuse food stamps.

[tritsofme]

128. Is the grocer reimbursed for less than 100% of the price of the purchase?

That would be the comparable example.

[cliffordu]

109. I just got turned down in THREE different places for residential treatment

for this little thingy I have with mood alteration......

NONE take medicare.

[MannyGoldstein]

110. That's fucked.

Sorry to hear it!

I think virtually all providers in Massachusetts take Medicare and Medicaid, I wish it were true all over!

We need Medicare for all. We need it now!

[cliffordu]

112. True, that, Manny -

Off to the Veteran's Administration for a place in line.

[MannyGoldstein]

123. Good luck!

I hear the VA is pretty good these days, but I guess they're overloaded with the fallout from Bush's excellent adventure.

[cliffordu]

125. Yep - getting more crowded by the day.

[guardian]

111. It is usually more likely the doctor is actually losing money for each Medicaid/Medicare patient.

It isn't that they don't "make as much money" they actually lose money. For years, doctors tends to limit their Medicaid/Medicare patient base to about 35% of the total patient base. This is when they broke even or perhaps made a little money. Then they overcharged the other 2/3 of patients to subsidize the Medicaid/Medicare patients. As reimbusements have declined lowering income combined with regulatory and other burdens have increased costs, many doctors are divesting their practices of Medicaid/Medicare patients.

This does several things. First, they can better service the other patients and still make money in the face of declining reimbursements from insurance companies/HMOs. Second, if they don't take any Medicaid/Medicare patients they can exempt themselves from numerous costly goverment regulations and oversight.

[Xithras]

114. My daughter will be about $300,000 in debt by the time she becomes a doctor.

She went to college with a head full of ideals and plans to dedicate her life to helping the poor. She's now trying to figure out which specialty will pay the best, so that she can have some sort of chance at paying that debt off. It's improbable that she'll ever see a patient on Medicare, or get to spend her life in some third world medical clinic like she wanted.

Obamacare did little to fix the core problems with our medical system. Only the wealthy and debt free doctors can afford to offer care at a loss...or even at a break-even price...and there aren't enough wealthy doctors to go around. It's mathematically impossible for a young doctor with school debt to do so.

[Yo_Mama]

159. Amen to that

I work (for free) for a 72 year old doctor working six days a week. He does not take Medicaid patients, although he will treat them for free if it's serious. But the Medicaid hoops are untenable for him.

He does take Medicare, although he has to be careful about it.

He treats many people who are theoretically insured for free, because their current insurance only kicks in once they reach thousands of dollars a year - and by the way, that means he actually pays money out aside from the normal costs, because he has to pay to record claims for them. He treats a lot of people who are uninsured, often for free.

He believes that if he takes on a patient he pretty much has the ethical obligation to see the patient through whether they can pay or not.

However, the only reason he can do all this is because he has other people doing a lot of work for him for free (otherwise his compliance costs for all the new stuff would have already put him out of business) AND because he is old and has already paid off all his loans, plus saved.

I think suggestions such as the one in the OP are an exercise in fantasy. What's really happening is that below-cost reimbursements are causing doctors to sell their practices to hospitals, so hospitals own the practices and can send everyone to the hospital for tests, which costs more because of their overhead costs (much of which are hiked by the obligation to provide free/below cost care).

This is an exercise in mass self-delusion. It is overall increasing costs and lowering quality of care, and blaming the doctors for the perverse economics is stupid. The insurance industry inflicted all this on us. But that's what we "bought in to" in ACA, so now we are all triply screwed.

Your daughter isn't going to get to really be a doctor because of a sick system, not because she wants to get rich.

[ecstatic]

120. I think many wish they could... Don't shoot the messenger but

here are the complaints I hear from providers: First of all, the reimbursement rates never go up, and as if that isn't bad enough, some honest, hardworking doctors find themselves having to give back money they were previously paid due to unfair technicalities, etc. (not referring to fraud). For example, Georgia has now hired a private accounting firm to audit medicaid/medicare providers and that firm has an an incentive to find as many things wrong as possible to ensure that they make the maximum profit. On top of all the extra paperwork and inspections involved in providing those services, Medicaid/Medicare get away with stuff that a private insurance company would never get away with and there's very little recourse for providers. Just sharing the other side of things.

[Sen. Walter Sobchak]

135. My doctor gave up his practice at the end of last year.

And accepted a position as a staff physician for an oil company. He said he simply couldn't make a go of it anymore. Every cost associated with his practice was increasing, while revenue had been stagnant for a decade as medicaid, medicare and insurance companies were out of touch with reality and too often payroll was coming out of his line of credit.

[SheilaT]

142. This has been a problem ever since Medicare started.

I have heard many doctors complain about the low reimbursement.

I know this from working as a registration clerk in a hospital: For a medicare patient, we have to do something called "code-scrubbing", meaning we have to check that when tests or procedures are ordered, the diagnosis needs to be one that indicates those tests are necessary. Sometimes we have to get the patient to sign and ABN, Advance Beneficiary Notice, which says that Medicare may not pay for the test or procedure, and if it doesn't we'll be billing them directly. If we don't get the ABN signed, and if Medicare does not pay, we cannot go after the patient for payment.

Now there are certain tests or procedures that will automatically generate the ABN. For instance, Medicare may only pay for one particular blood test three times a year, and when that patient shows up for the test, the system has no way of knowing the last time they had the test.

[pediatricmedic]

145. No, not unethical to demand a living wage

Medicare/Medicaid just don't pay a living wage to a doctor or their staff.

[David__77]

147. Mosy physicians in the US are no longer in a position to individually make such a decision.

Most are salaried employees of hospitals and medical groups and medical directors (who are often non-practicing physicians) set such policies in conjunction with others. Am I wrong?

My mother goes to physicians that are attached to a public university hospital. They are all salaried and could care less if their patient is Medicare/Medicaid, except they may have their biases. It doesn't affect their paycheck. The hospital policy is to take such patients, but that's here in California.

[BlueCheese]

148. Is it unethical for any person not to help someone who can't pay?

I feel like the question as asked shouldn't be restricted to doctors. Many people are able to provide important services that other people need-- doctors, plumbers, teachers, etc. There are many people who would benefit from using these services who can't afford it. Is it ethical for the service providers to only treat people who can pay?

I would argue that it's much like charity in this case. I wouldn't presume to tell a doctor that it is her duty to sacrifice her own interests to treat patients (for non-urgent problems), but I would admire someone who did so.

[Donald Ian Rankin]

149. Only if it's unethical for you, personally, not to meet strangers' health-care costs singlehanded.

What *is* unethical is for the state not to provide decent medical coverage for those who can't afford it - or, ideally, for all.

But there's no more obligation on doctors to cover for that failing than there is for anyone else.

[Phentex]

153. Amen. n/t

[AngryAmish]

158. If they don't refuse, how the fuck are the doctors supposed to pay for their Maseratis?

Jesus. Do you think country club dues are free?

[Yo_Mama]

160. Response from an angrier Mennonite

It's unethical, if you can pay, to refuse to pay someone for their work. And it's unethical, if you can help, not to help. It is also unethical to demand so much that you destroy a resource which is necessary for the life of the community. It is unethical to demand more than the fair value of your work.

Now if you are Amish, you should know all that. You should also know that the reason that our more traditional communities frown on insurance is that it leads to everyone denying responsibility for the life of others, which is unethical.

Your response is immoral, because it denies the reality of what is happening. Look up Medicaid reimbursement rates in your state. This is an obligation of us all, not just the doctors. Your response is a lie.

The doctor I help out, who is profoundly ethical, although he isn't Mennonite or Amish, but Catholic (which under DU orthodoxy provides another reason to scorn him), can no longer afford to heat his office above 60 in the winter or run the AC to keep it below 85 in the summer, and he's basically working for free, but yeah, go ahead, and claim the problem is solely due to the desire for Maseratis. You see, if you do act like you think doctors should, the word spreads and the next thing you know your time is filled with non-paying patients.

It is attitudes like yours that prevent us from actually fixing the medical funding system in this country. You have the right to be a self-righteous fool, but doesn't it bother you to think that this surge of glorious well-being comes at the cost of not dealing with the real inequities and thus endangering the welfare of millions?

You've got a brain. Use it. What would happen to us all if we decided to cut food stamps and instead loudly proclaim that supermarkets should ethically provide food for free or below its purchase cost to those who can't feed their families? Wouldn't it be the case that the most ethical supermarkets would respond to that claim, and then that they would be flooded with customers who can't pay the cost? And wouldn't those supermarkets then be unable to maintain facilities, be crowded, etc, and then raise their prices for those who could pay? And wouldn't that mean that those who WERE paying would be more likely to go to a cheaper supermarket? So wouldn't this theory ultimately leave an awful lot of people hungry?

The reason we don't have socialized health care in this country is that the way to fund it is from payroll taxes, and in this country, well-off people don't want to pay those taxes. It's that simple - but go ahead, blame the people who are trying to provide medical care to the underserved because they don't HAVE ENOUGH MONEY TO TREAT EVERYONE WHO IS UNDERSERVED. Because that's really, truly going to help.

[Phentex]

162. You get it...

Thank you for a civil, well thought out response.

[IdaBriggs]

168. Amen! I did the math up above in post #161.

$26,700 just to break even with a garbage man, not including living expenses, taxes, business expenses (other people's wages and equipment), and (heaven forbid!) a family life, all while working 50+ hours a week if you are a "Part-Timer" while on call for emergencies at all hours of the day and night.

But "playing dumb" about the investment required to be able to perform the services -- don't you know they are all RICH?

[Yo_Mama]

169. I found it, that was quite realistic

There was a time in the US when only rich people could afford to become doctors. I don't think that was good. I would hate to return to that model.

We could fund medical educations, which would take some of the cost pressures off them, and bring more people into the profession so that they could be there to treat people. However your basic point still holds - when you defer your "earning life" so long you do need to make more relatively while you are working in order to end up with similar lifetime net.

Right now, most younger primary care physicians may end up poorer at 65 than a teacher of comparable age. I think teachers should be paid well, but it is unrealistic to expect people to do this for anything but the love of it, and to add recriminations and insults on top of it - not a good plan.

Another thing that people are not even considering is that as the baby boomer population ages, a significantly larger portion of the whole population is going to be on Medicare, raising the relative burden of providing lower cost care to Medicare patients. The numbers of Medicare patients plus Medicaid patients are ballooning, and we will be rapidly adding more due to ACA and retirements:
http://www.census.gov/compendia/statab/2012/tables/12s0146.pdf
(only through 2009, numbers have increased since then.)
http://www.ssa.gov/policy/docs/quickfacts/stat_snapshot/
When 30% of the population is on either or both of these programs, and we still have millions of uninsured to care for, is it even remotely reasonable to expect physicians to be able to pick up the costs?

We are not stupid enough to believe that gas stations will give us gas for free, or that supermarkets will give us food for free. Why are we stupid enough to believe that doctors can treat a whole lot us for the less than the cost of providing the service?

[IdaBriggs]

170. I think you hit the nail on the head with your observation about "rich doctors" --

at one time those where the only people who could afford to spend the time/money gaining the necessary skills, and that stereotype is still a part of our culture. I think even our young physicians have it - people will "always get sick" so it is guaranteed income after all. (Insert eye roll here)

At the heart of it, medicine is a SERVICE industry; the same people who would be up in arms at "not tipping" waitstaff automatically assume that a doctor should give his skills away for free, while paying rent on the building they are seen in, electricity/heat/water/phones for same building, a receptionist to answer the phone, medical billing folk to help with any insurance paperwork requirements, and a nurse or two to assist with patient care, all while giving free samples of any medication they need.

The only "charge" seen is the "physician's time" which has to cover the cost of a minimum of three support staff plus facility costs. So, the actual cost (roughly):

$45 per hour for physician (20 minutes with patient, 20 minutes of record keeping/paperwork)
(assumes $26,700 in "make up/student loan" money, $30K in taxes, and $40K in living expenses, etc for a "big salary" of $90K)
-----
$30

$30 per hour for nurse (20 minutes with patient, 20 minutes of record keeping/paperwork)
------
$20

$20 per hour for medical billing specialist (30 minutes per patient)
------
$10

$15 per hour for receptionist (30 minutes per patient)
------
$7.50

Benefits, Insurance & Appropriate Taxes for Staff (Average $15K per year, $7.50 "extra" per person per hour * 3 divided by 3 patients an hour)
------
$7.50

Facility Cost (Rent, Utilities, Phone, Building Insurance, Etc. Approximately $3,000 monthly, divided by 22 working days and 20 patients daily)
-----
$6.81

To summarize

$30 Doctor's Time
$20 Nurses Time
$10 Medical Billing Time
$7.50 Receptionist Time
$7.50 Staff Benefits
$6.81 Facility Cost
------
$81.81 to break even for 20 minutes of "face time" with the physician, if everyone works REALLY CHEAP!!!

[Rex]

171. Me personally, I think it is low class and wrong.

However, if it is a private practice then they can refuse service to anyone.

[Egalitarian Thug]

176. Anyone interested in making a list of DU's most consistent reich-wing defenders

can just look down this list of replies.
and