A Conversation with My Doctor

I just had a conversation with a doctor who has been trying to keep me healthy for a while, a sweet man, and we often chat a bit. I asked him what he was rooting for in this health care debate. Mediare for everyone. He launched into how much it cost just in his office to deal with all the different insurance plans. They have a number of people whose full time job is to handle insurance. The cost to the practice is in six figures. With Medicare alone, they could cut that by a third.

He fleshed that out with examples of company requirements that flew in the face of the standard of care to which every patient is entitled, particularly requirements of pre-authorization whose only function is to delay needed treatment if the doctors are lucky enough to realize they have to get pre-approval.

So I asked him whether Medicare paid enough. He responded that it was certainly less than his fee but it was enough. He didn’t need to become rich, but it paid the staff and other overhead and enough for himself and his partners.

Then I asked him about Medicaid. They paid so little, his office didn’t bother to bill for it. If a doctor referred a Medicaid patient with a serious illness they would handle it pro bono. There isn’t even a tax deduction. There has been a lot of discussion of patients going to emergency rooms. But I hadn’t thought of the hidden cost to the doctors who treat patients who are uninsured.

And the change of Blue Cross from non-profit to a private for profit entity? He responded that before the change the company was much more reasonable in its reimbursement practices.

This has been a sea change among the doctors. In the 1960s, when the American Bar Association was joining the effort to make legal services available to the poor, the American Medical Association was fighting against the Medicaid and Medicare programs. But the deadweight of conflicting billing practices, the time it takes the doctors and their staffs to do the paperwork, instead of attending to their patients, has changed their minds. Many of them tell me that medicine used to be fun. They got into medicine because they enjoyed the practice. But the paperwork that takes time away from their patients and in some cases the expectations by the insurance companies that patients are only worth five minutes of a doctor’s time, have taken the pleasure out of practice. So the various medical associations have changed their view. They are not afraid of government. They’ve learned to work with public programs.

When I served in the US Peace Corps in Iran, our doctor was provided through the US Public Health Service. Bob is still a friend and has gone on to a very successful career including a decade and a half as dean of a prominent medical school. Neither of us thought the government was the enemy or of each other as a government agent. Government, and the two of us, had jobs to do and we all did our best. As in private industry, some programs are well conceived and some are not. But generalizations about government or private industry are just garbage thrown around by people who don’t know better or don’t care if they do.

Stripping government of capacity to deal with problems is a serious problem. It means life much less fair, much less safe, and, in the case of health care, much shorter. All the rhetoric about the great health care in the US can’t hide the embarrassing fact that life expectancy is much greater, for people of all ages, in other parts of the world. So we are either a great enough country to acknowledge reality and deal with it, or we are not.

— This commentary was broadcast on WAMC Northeast Report, December 15, 2009.