Reimbursement, Prepare to Die!


“Prepare to Die”, said Inigo Montoya to the six fingered man.

Reimbursement, prepare to die.

Doctors get reimbursed? Interesting….

Do Lawyers get reimbursed? Do accountants get reimbursed? When you send your check to pay for your Aetna premiums, are you reimbursing them?

The last time I checked, the act of being reimbursed implies that a person gave money and awaiting for someone to give them the money back.

Let’s take a quick look at Webster’s Dictionary.
reimburse |ˌrē-imˈbərs|
verb [ with obj. ]
repay (a person who has spent or lost money): the investors should be reimbursed for their losses.

• repay (a sum of money that has been spent or lost): they spend thousands of dollars that are not reimbursed by insurance.
How did it come to pass that doctors don’t get paid, but reimbursed?

Straight out of the Princess Bride when Inigo Montoyo says to Vizzini, “You keep using that word!, I don’t think it means what you think it means”. (watch video for effect)

When did getting paid turn into getting reimbursed? Oh, right. It doesn’t. We need to stop using this word in healthcare. I can assure you, this linguistic gymnastic was not conceived and promulgated by physicians…can you guess who?

Let’s see, who in healthcare would like to create words that change the way we perceive how money flows…hmmmmmm

Health insurance used to reimburse the patient after they PAID the doctor or hospital.

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I am convinced this is not an epiphenomena of the principal agent problem, but rather a quasi pre-meditated effort to make society uncertain about how money flows from your pocket to payor coffers. For those of you who are not familiar with the principal agent problem, it is a well known economic term that means: when one doesn’t pay for the good or service they’re getting. (see diagram)

I am not just cracking it open but am exposing it as a mechanism to obfuscate the simple principal and process: I work and I get paid for that work. I buy something and I pay for that something.

It’s crazy that someone hasn’t spoken up earlier. We are far down the rabbit hole of making reimbursement a fixture in national and local healthcare dialogues and it needs to stop. Now!

Repeat after me:

I will use payment from now on, and never use the word reimbursement again….and if I do, I don’t think it means what I think it means.

I will use payment from now on, and never use the word reimbursement again….and if I do, I’m a knucklehead.

We need to cleave this toxic rope in healthcare’s Gordian knot

that has polluted our medical nomenclature once and for all – this is one of the most insidious, evil of the words in my series.

Please don’t use it anymore. Please.

For the love of Inigo Montoya, clarity and our healthcare system:
“Please stop saying that word!”

(small qualification is that some places actually do buy vaccines, medicines and equipment for resale and then do actually get reimbursed for the money they spent, however, this is a micro-fraction of the $2,600,000,000 dollars spent in healthcare ~ yes, that’s $2.6 trillion)

26 replies »

  1. Patients lost sight of the cost of care when the “third party” insurance company entered into the equation. Physicians lost out when they agreed to become “providers” for insurers (government or private) and let the third party dictate what their fees would be. So now we have a convoluted, expensive system with access and quality of care declining. Payment/coverage policies are designed to keep money in the pocket of the insurer. They have very little to do with what the physician feels is best for the care of the patient. I fear that regulatory mandates will only increase this interference in the physician-patient relationship. And now, I will be financially penalized should I choose to cut out the insurance middle man and go with a concierge type practice for my medical care. Ridiculous!

  2. Can we stop calling health insurance health insurance, too? Because it’s not really insurance considering all the benefits it is required to cover.

  3. This has nothing to do with the author. It has to do with you and your misuse of the word ‘wages’.

    To you healthcare is politics. To me it is delivering healthcare.

  4. “This dispute involves nothing more than the English language that you may or may not want to pervert for ideological reasons.”

    You think the author posted his view to engage in a pure english literature discussion? Healthcare is nothing but “ideology”, same as all politics in this country.

  5. I don’t when that is what they are being paid. There are salaried physicians and there are physicians that are not salaried and depend upon fee for service.

    This dispute involves nothing more than the English language that you may or may not want to pervert for ideological reasons.

  6. Your employees were paid “wages” because that’s the accepted practice and you were able to know your costs when quoting and performing jobs. I don’t have a problem with that. Why do you seem to have a problem with paying docs a salary?

  7. My employees were paid wages because they had fixed regular payments. My payments weren’t fixed or guaranteed. If I did no service I didn’t get paid. If there was a holiday I didn’t get paid. I only got paid a specific fee for a specific service.

    Do you have a problem?

  8. “wages” are a fixed regular payment so your use of the word is out of the question making one believe you have a secondary misplaced motive.

    Perhaps the use of the word ‘wages’ was an attempt to climb the ladder up by pulling another down.

  9. I think “payment” should assume we know the price before service is provided or the product is used. Even lawyers draw up a retainer agreement before their service is used.

    Post your prices Jordan?

    Further, cash pay customers make payments, insurance provides reimbursement. One term I’d like used for doctors compensation is “wages” and not FFS.

    Whatever term you use the costs are out of control, changing the term does not change that.

  10. Very interesting.

    Recalling when Medicare began using the word provider, do you see some sort of similarity? Medicare wants to change the nature of physicians converting them into widgets.

  11. Miracle Max: Have fun stormin’ da castle.

    Valerie: Think it’ll work?

    Miracle Max: It would take a miracle.

  12. Indeed, very true. I will be writing many posts on ‘cracking open medical jargon’ in an effort to make transparency = better outcomes for people.

  13. I am all for paying providers (a term I like because, in reality, any person a rendoring healthcare service is just a vendor to the patient or customer, and the sooner more people grasp that relationship the better). The problem with payment, of course, is who decides what the market will bear and whether providers can abide the market’s judgment.

    Many years ago, Uwe Reinhardt wrote a very amusing essay on how it was easy for the sports market to value Dwight Gooden in his prime. Maybe not so easy to value docs and decide who “pays” them and how much. Despite the often acidic things I write about physicians, I like my present and most recent past internist. In part, because I hardly ever needed them and they left me alone.

    But, they aren’t Clayton Kershaw, who just won his third Cy Young. They know they aren’t and they don’t try to pretend that they are. To stick with the baseball theme (and as a Pirates fan, keep it Pittsburgh centric), to me they were Franciso Liriano of 2013. Here’s where it get sticky: a lot of docs think they are Clayton Kershaw, and I will wager that you can assemble no jury of their peers who will agree with them, but they are legends in their own minds. Unlike in sports, where there are clear, hard lines of demarcation that separate the wheat from the chaff, in medicine, everyone with a white coat thinks they’re a white knight (yes, I know I mixed metaphors). Hardly.

    Confusion in medicine and healthy policy is intentional, because it benefits people who are technically, financially, and adminstratively savvy and builds a wall that keeps the barbarians away from the aristocracy.

  14. Another phrase I hate: “revenue cycle” — e.g., the (lengthy) interim spanning the time you book at pt appointment through the time you actually get paid for the subsequent encounter.

    Hardly unique to healthcare (lots of businesses “game the float”), but at its worst therein.

  15. It’s interesting that there is so much obfuscation in medicine. Certainly, payment and billing create trails that are nearly impossible for even the most informed patients to follow. We’ve established a system where those paying for services have no way of knowing at the time of service how much they will be paying, and what they are paying for. It makes me think back to a low-cost cash model for payment in medicine that I saw where all visits and tests were visible to the patient beforehand, and in this manner, the patient could make informed choices about what he/she wanted to buy.

    We see medical obfuscation entrenched in such terms as “Provider” (which inherently creates an imbalance in the relationship), and diagnostic terms like “idiopathic,” which simply means “we don’t know.” Perhaps, as a society, we shy away from saying words like “paying” for medical care because care is something that everyone should have, and “reimbursing” for care is a euphemism that allows us to avoid saying “payment,” as if the latter were a dirty word.