Physicians

PHYSICIANS: How to easily increase access to care, by Eric Novack

NovackEric Novack is an orthopedic surgeon who went to medical school in liberal San Francisco, but is now practicing in the red state of Arizona. Eric has been sparring with me and others in the comments on THCB, and also has his own weekly radio show. It’s on a station called "960 The Patriot" — and you can guess that it’s line up is a little different than San Francisco’s 960 The Quake, which is our local Air America affiliate. Eric’s weekly show is very well done, and I recommend that you head over there to take a listen to his archived shows. Some of you might perceive a bias in his guest line-up, and Eric has strong opinions on policy, many of which I do not share.  But I’m very hopeful that by encouraging Eric to write for the blog, (and we are also planning some podcast conversations in the near future), we can get to some of the heart of the issues about which we disagree. For his first post, Eric starts simply, with an idea to get physicians to provide more uncompensated care.
In what I hope is the first of many posts for THCB, I propose a simple step to increase access to care. The number of uninsured is large. Depending upon your perspective, the number can be as low as around 20 million Americans or as high as 45 million. Of course, you can find those who claim a number larger or smaller. It is a great bit of semantic legerdemain to equate lack of insurance with lack of access to health care. Stating "no access" implies that no care is available and that the government has "abandoned" this group. This is simply not true.

Congress passed a law in 1986 called Emergency Medical Treatment and Active Labor Act" or EMTALA. EMTALA has a variety of provisions but can be simply stated that persons who come to emergency departments cannot be turned away because of an inability to pay. This applies to the hospital emergency department (ED), the emergency room physicians, and the specialists and internal medicine doctors "on-call" for the emergency department. "Emergency" for the purposes of the emergency room is anyone who comes to the hospital– the hospital cannot say– "it is just a cold, so we will not treat you". If someone breaks a leg and an orthopedic surgeon is on call to cover the ED, the surgeon must take care of the problem and the patient including the operation and all appropriate follow-up care.

One of the many problems is that all of this uncompensated care falls back on the doctors– remember that many hospitals are non-profit or have received federal funds that require them to provide a certain amount of uncompensated care.

Let me give an example, (any similarity to any real patient of mine is coincidental…). I am on call for "Arizona Hospital". Bill Jones is brought to the hospital after a fall from his ladder at home, where he was taking down his Christmas lights (it is never too late, is it?). I am called by the ED because Mr. Jones has broken his femur (thigh bone). I see the patient in the ED, he is admitted, and I operate on him at midnight. I finish surgery, the paperwork, and head home around 2:30 AM.  I then see Mr. J for the next 3 days after clinic. After discharge, Mr. J comes to the clinic regularly over the next several months for checks and x-rays and advice and guidance. Total charges for all the work, time, expertise, and liability risk is $5000.

Mr. Jones has his own landscaping business.  He has no insurance.  He never pays a bill.  I cannot abandon his care– it is unethical and against the law (abandonment). I get tired of this happening and stop taking call at the hospital. Losers in this scenario–the physician, the hospital (less coverage), and future patients–insured or not- who would benefit from my expertise.

Here is a partial solution– but first, a brief preamble. Health care system transformation will need to be incremental, not revolutionary– otherwise, the kind of horse-trading and compromises that resulted in the bloated, inefficient, restrictive system of Medicare result.

Here’s the partial solution. Guess what happens at the end of the year when I file my taxes?  Can I deduct the $5000 in bad debt as a "business loss"?  No. By simply allowing physicians to credit bad medical debt from their income (like other businesses can with losses related to products, etc.), physicians would be have a huge incentive to provide a certain amount of care to the poor. It needs to be a credit and not a deduction as a deduction would return only 35 cents on the dollar at best. So, there it is– tax relief to the providers of care for the amount of "free care" provided. 

No new bureaucracy.  Incentives, not punishment

For some more info on EMTALA see this lawyer’s site.

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Nirav
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Nirav

From a doctor’s perspective who hasn’t yet joined the old boys club – if there is one…, I don’t think most physicians wouldn’t be happy to do our share to help the poor but we want people held accountable. How do we properly identify the working poor when they walk into our clinics. I see too many “poor” people with ring tones, Nike Air Max, and Starbucks (luxury items). The grumble at the high co-pay because we have been trained to make healthcare the last thing we pay for. The uninsured working class cannot get affordable healthcare because each patient… Read more »

anoni
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anoni

Bootstrapping, conservative perspective outlines that NAFTA is good. Well NAFTA is set to be extended to the Trucking Industry. Why not extend it to docs? That way docs dont have to inconvenience themselves with nobly not abandoning a patient who cant pay.
I think docs are overworked and overextended. They should be given a break, and the market of providers can be increased.
Personally, I go overseas, but would love a free trade arrangement that allowed those services to be provided here.

Miles
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Miles

I read all of the above with great interest. I wonder how many who read this whole thread missed the major point at the beginning…..The doctor had no choice but to treat the patient in the middle of the night.
He then does not get paid.
This is different than any other business that does not get paid.
Charity when it is either expected or compelled is another form of slavery.

Nancy
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Nancy

No one has pointed out a gaping logical hole in this proposal.
To wit: Giving Dr. Novack a $5000 credit is not in any respect different than the governnment paying Dr. Novack the money.
People tend to assume that tax credits, deductions, etc., are a painless way of getting something to happen but in fact every single one cuts into tax revenues and affects public budgets in EXACTLY the same way as if the money were collected & then spent.

spike
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spike

Yeah, my thought on this is that it’s hard enough to maintain a fraud-free system where you actually have trained people reviewing claim forms. How easy would it be to commit fraud in this system?

Ron Greiner
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Ron Greiner

Dan,
You forgot to say how much your Blue Cross coverage costs. Tell us which Blue Cross plan has a dependent coversion priviledge that allows children to move to 43 states and keep their coverage.
Please Dan tell us the state of your Blue Cross plan and if it is individual or group coverage from an employer.
Liberals never discuss costs for insurance they only scream about deductibles.

dan
Guest

Thanks, Eric Your new suggestion: that “with some kind of ‘proof of hardship'”, those without insurance could get care “at no cost to them” sounds great! But it’s not in your original post, or anywhere else in your comments on your proposal. I like the idea that ideas can evolve through dialog on blogs, and the conversation here is very productive. I hope that in your future posts on this proposal or other topics, you’ll include this key element of your evolved proposal just as you stated it here: free care for those who need it. That element is obviously… Read more »

eric novack
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Dan- A presumption, I believe, is that the main reason people do not go to the doctor for routine, preventative care, is economic– those without insurance cannot afford to go to the doctor, are afraid of big bills, therefore end up with much worse, more expensive medical problems. If that same group knew that, with some kind of “proof of hardship”, that the care would be no cost to them, people would be more likely to seek out simple, efficient, preventative care. You are correct in that this is not how things are now– the post is a proposal for… Read more »

Oskie
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Oskie

At the end of the day, no one will work for free–certainly not doctors–any rational plan for health care reform must fairly compensate those individuals (doctors, nurses, technicians, and allied health practitioners) who have made it their life’s work and career to take care of sick people.

dan
Guest

Eric, You still haven’t answered the key question: how does your proposal of tax credits for doctors help achieve the title of your post: “How to easily increase access to care”? I’m repeating myself from yesterday, but you still haven’t answered: your idea is great for doctors, but does nothing to help those who cannot go to the doctor OR the ER because they are uninsured and don’t want to be forced into bankruptcy. Your original post is based on the myth that people get free care in the ER. That’s simply not true: regardless of insurance status or ability… Read more »

Eric Novack
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Spike- I sense that the essence of one prong of the “pro-medicare for all” solution has to do with overhead calculations: The magical 3% overhead number (administrative cost/ benefits) appears to come from a Kaiser Family Foundation study from 2003 (author Merlis)- There are reasons that can account for much of this: 1. elderly populations are going to have more spending per enrollee than younger, healthier populations 2. inadequate oversight or an actual lack of administrative oversight (to reduce the fraud many THCB readers feel doctors are guilty of) will make it seem more efficient. This is a summary from… Read more »

spike
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spike

Well, we currently have the worst of both worlds, right Eric? I mean… are you saying that we don’t have a system of yearly lobbying campaigns where drug companies and other groups lobby to get certain procedures covered, etc.? We already have most of the negatives you discuss from Medicare, but none of the positives of Medicare for all. Yes Medicare does have a lot of codes behind it (you neglect to mention that no single provider has to know anywhere near all of the regulations), but so does every private insurer out there. The private insurers do the exact… Read more »

matt
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matt

“I don’t know how Medicaid works, but it seems to me that you could require doctors to obtain a signature from the patient attesting…”
Where there is a will there is a way to commit fraud. There is a rationalization among some physicians (and hospitals) to commit fraud “to make up for” cuts in reimbursement and other real and perceived compensation cuts.
Physician fraud isn’t a trivial problem. Eric’s proposal would significantly add to the problem.

Eric Novack
Guest

Well put– and, possibly, the question about healthcare– Why not medicare for all? Here, of course, is where the opposing camps can provide much data and survey information, etc. Issues to consider: 1. Medicare has 150,000 pages of regulations 2. Current coding for doctors requires 10,000 different codes from which to choose. The “next generation” coding book (ICD-10) has 40,000 codes from which to choose in order to be able to bill. 3. The cost of compliance– the figure that medicare runs 3% overhead does not count the additional overhead costs that physicians (and hospitals) must account for to comply… Read more »

Abby
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Abby

Eric, I was only joking about the belief that people are fundamentally bad. I was cryptically alluding to a kind of Burkean belief that grand schemes are likely to cause more harm than good. I tend to respect that sort of conservatism. Indeed, I’m in sympathy with it. I was basically stealing the line from publius of law and politics (an ex-conservative). His post on the subject is here: The market is brilliant at providing cars, but why health care. How do you decide which services the government should provide? Should we all buy fire insurance (by which I mean,… Read more »