Eric 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.
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.