Paying for medical care

While we anxiously await the decision of the Supreme Court on the Affordable Care Act, let me offer you three thoughts.

1. Health care for all is only possible if those of us who have money and jobs pay for those who do not.

I love it when people say, “Let the federal government pay for it.” Who do they think funds the federal government? Ditto for “Let the states pay for it.”

What about “cost shifting”? Put a surcharge on health insurance so that the extra money can go to those who cannot afford to buy health insurance. Don’t look now, but that means that those who have the money to buy health insurance will be paying for those who do not.

How about mandating that corporations contribute a percentage of their profits to a fund that supports health insurance for the needy? That will make the price of everything that corporations sell rise, shifting the burden back to those who have money to buy those things.

2. An old axiom in business is appropriate for health care too. It goes like this, “You can have affordable health care, access for all and high quality, but you can only have two of the three.” There is no way that everyone can have every test for every disease.

For example, many guidelines suggest that everyone over the age of 50 should have a colonoscopy. According to the last census, there are 40 million people in the US over the age of 65. Can Medicare pay for 40 million colonoscopies? Even if it could, there are not nearly enough qualified colonoscopists to do the job.

3. According to Supreme Court Justice Elena Kagan, “You are entitled to health care when you go to an emergency room, when you go to a doctor, even if you can't pay for it.” [See page 74.] If you want to have a little fun, mention this in a roomful of physicians.

Maybe Justice Kagan can tell us how we are supposed to pay our rent, malpractice insurance, office staff, workers’ comp, other benefits etc, if we see patients who can’t pay? Oh, universal health insurance? See #1 above.

What do you think of my three thoughts?

Washington State Medicaid will no longer pay for “unnecessary” ED visits

By now you must have heard the news that as of April 1, Medicaid in Washington State will no longer reimburse hospitals for care of what Medicaid deems unnecessary ED visits. [The Seattle Times report is here.] The problem, of course, is that many times the perceived lack of necessity can only be determined after the patient has been worked up. Even a patient brought in by ambulance will not be covered if it turns out that his illness is not a true emergency as defined by the rules. And hospitals will not be allowed to bill the patients. The unnecessary visits list includes illnesses like hypoglycemic coma and asthma attacks. Unstable vital signs do not matter if the visit is eventually found to be unnecessary.

Hospitals and ED docs in Washington have vociferously objected to this patently stupid plan but so far the state’s Medicaid boss [a doctor] is standing firm.

In addition to the obvious problem of not knowing whether a patient is sick or not before he is examined, what is an ED doc supposed to do if an ambulance brings in a Medicaid patient with a cold? Should the patient be refused entry into the ED?

That probably would not be wise because of a federal law known as EMTALA [Emergency Medical Treatment and Labor Act]. From the website EMTALA.com: “EMTALA requires most hospitals to provide an examination and needed stabilizing treatment, without consideration of insurance coverage or ability to pay, when a patient presents to an emergency room for attention to an emergency medical condition.”

What happens if EMTALA is violated? “A hospital which negligently violates the statute may be subject to a civil money penalty (i.e., a fine, but without criminal implications) of up to $50,000 per violation. If the hospital has fewer than 100 beds, the maximum penalty is $25,000 per violation.”

Anyone who works in a hospital knows that EDs are being inundated with patients who don’t really have emergencies, but shifting the blame and cost to the hospitals and EDs is not the answer.

Like many issues today, personal responsibility is no longer expected or required. The Medicaid card is the “everything” card. Get one and you’re all set. I worked in a city hospital for several years. The Medicaid patients had absolutely no interest in controlling costs. They knew that if they went to an ED, they had to be examined and treated.

Assuming that there are enough primary care doctors, accountable care organizations or “medical homes” in the State of Washington to accommodate the no longer ED-bound Medicaid population [a factor that apparently no one has brought up], wouldn’t it make more sense to shift the responsibility of deciding whether they should go to an ED to the patients themselves?

But that would require some restrictions on the “everything” card. I doubt that any politician or bureaucrat would have the balls to even suggest, much less implement, such a policy.