Tina Dupuy: Try living uninsured

The other day, I admitted to a friend that I don’t have health insurance.

“What?!” he gasped. “But you’re married. Isn’t that part of the deal?” He reacted as if I had just told him that I believed in Santa Claus or the Easter Bunny or a flat tax — something embarrassingly ridiculous. Because that’s what being uninsured is these days — a character flaw. It’s how you can pay taxes, volunteer, donate to public radio and still be considered a drain on society.

As my friend was, you may be wondering, “Seriously, how can you not have health insurance? Don’t you work? Are you illiterate? Do you have no self-worth whatsoever?!” The short answer is, my husband and I are both freelancers so we have no workplace insurance. And the $500-plus monthly premium? You might as well say our health depended on our adding a new wing to our apartment.

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Posted in * Culture-Watch, Health & Medicine

62 comments on “Tina Dupuy: Try living uninsured

  1. Sidney says:

    She can’t afford $500 per month? Baloney. They pay more than twice that in rent. Move to a less expensive city (in a nice cold place, maybe). Or get more reliable income. If health care were considered an essential, the cost of rent and other things would be lower (from lower demand). I’d love to see this woman’s monthly budget.

    That’s the truth about this health care crisis: many – perhaps not all – Americans without insurance can afford it. They choose not to.

  2. Dave B says:

    Sidney, the democrates are either going to garnish wages (Hil) or make it a criminal offense with fines ( Obama) for not having it. That will solve the crisis!

  3. sarahsnemisis says:

    Sidney,

    As a person who self-insurers it is not as easy as you think. OUr family policy- for a family of 4 healthy, non-smokers- is $990 a month. This is for a policy with a large carrier and it has a $1000 deductible for each member a total family deductible of $3000 and maximum out of pocket of $9,000.

    It is decent-to-sub-par coverage, but is still very expensive- our house payment is less than this deductible.

    I don’t think it just an issue of affording something. The insurance company would drop us or raise our rates if we have just one major illness.

  4. Jim the Puritan says:

    Guess what, it gets much worse once you have children. My wife and I shell out a total of $1600 a month in premiums for health insurance for ourselves and our two children.

  5. David Keller says:

    Sorry Sidney. When I left my 150 member law firm in 2005 and went out on my own I was on Cobra @ $1300 a month. When Cobra ended I was only able to find one insurance company that would insure me and my wife. Had we been in our 20’s it might not have been a problem, but we were both 55. I found ONE company who charged $900 per month with a $5500 deductable. It excluded heart, arthritis, allergies and knees. It was essentially a get hit by a truck or die of cancer policy. I could have gotten a policy through the bar with no exclusions for $1900 a month–but do the math. Even though I have a very reasonable income, my wife had to take a job just so we could get affordable insurance. My son who is 26 has good insurance through his employer, but from the time he graduated from college until he finally found a stable job he had nothing. He couldn’t get it at any price because he had some significant health problems as a teenager. Many kids these days are taking jobs well below their abilities and aspirations just so they can get benefits. I also have a friend who is 66 and on Medicare. His wife is 58 and he is going to have to stay on his job until she turns 65 because she can’t get ANY health insurance due to pre-existing problems. Before anyone asks, I am not a Democrat, but I can tell you from personal experience (and frustration) our health care and health insurance system is in crisis.

  6. Patti says:

    Seriously, Sidney? People who are self-employed (she says she and her spouse freelance) should not live near where their work opportunities would be so they can “afford” health insurance… but potentially have no income? Sounds like a catch-22 to me.
    I have no faith in the government to properly administrate health insurance for uninsured people, no matter the reason they are so. Various state attempts result in expensive, sub-par coverage that only covers well-care and has ridiculously low caps on medication benefits (after significant deductibles). The government may be able to be part of the solution, but the government isn’t itself the solution to the healthcare crisis.

  7. Terry Tee says:

    I read the above and shuddered. Suddenly our creaking National Health Service here in the UK looked more attractive. BTW, my dentist now will only treat me privately. I have to have a new crown which will cost me all of … US $700. I am left wondering why everything is so darn expensive in the US when it comes to health care. The dental work would cost me much, much more in the US. And please do not tell me that would be because I would be paying for state of the art R & D.

  8. RoyIII says:

    We should have a national health care system like most of the rest of the civilized world, england, france, scandinavia, etc. As it is now the doctors and patients both are ripped off by the insurance companies. The military, retirees on medicare, children and the disabled on medicaid seem to do ok with their health care.

  9. Jim the Puritan says:

    #7–Tell me about it. Even with paying more than $19,000 a year on health care premiums, the benefits continue to go down and down. I have to take a prescription pill every day. (I’m otherwise healthy.) A year ago it was free. Then it went to $35 a month co-pay (portion not covered by insurance). Then it went to $55 a month co-pay. Now it’s 2008 and I went into the pharmacy to refill it. It’s now at $175 a month co-pay, just for the one prescription.

    The cost without insurance–according to the pharmacy receipt: $450.

  10. Cennydd says:

    Let’s see; my son and daughter in law, who live in Daly City, California, are field test engineers who, between them, earn about $90,000 per year, and who live in a very nice doublewide mobile home, with their young son, manage to afford health insurance for all three of them.

    Semms to me that Ms DuPuy and her hubby have their priorities a little skewed.

  11. Cennydd says:

    And the health care for my wife and me? She’s covered by her former employer until her Medicare A&B;kicks in later this year, while I’m covered by Medicare A&B;and the Veterans’ Administration……except for dental care. Our daughter and her family have their own private plans……and they’re expensive and barely affordable.

    Health care for those without coverage in this country is an absolute disgrace…….and it’s an embarrassment for our country!

  12. Kaye says:

    I am 66 years old with Medicaid and fully paid lifetime BC/BS from my former employer. I am recovering from a prostate operation and 39 radiation treatments all paid for by insurance. I feel so blessed but the flip side of the coin is my wife can’t get insurance…she is totally disabled. She has pending workman’s comp. case going for three yrs. now and her SSI pending now for 2 1/2 yrs. I wonder what would have happened if my illness (different for of cancer) had happened to her…to us?
    Our monthly income (Mine including ss. is less than $2,000.) I pray and worry about her and something happening to her. Our Dr. Donates to her the meds. she needs. Without that her meds would cost hundreds of dollars a month.

  13. jamesk says:

    Yes, it’s not good, but government payors aren’t the answer. At best, medicare (the best of the lot) pays 40 cents on the dollar for hospital and professional services and they are awfully selective. by that I mean that in many circumstances they aren’t paying enough to make taking care of a patient a financially viable proposition. Literally. The way in which the UK and other single payor systems make it work is to 1) ration health care
    2) decide on a group rather than an individual basis what is going to be allowed.
    3) employ physicians primarily and thus disincentivize them.
    (would you like the guy taking out your gallbladder to care just as much as the drivers license clerk?)

    I also pay a lot for somewhat spotty coverage, but I’m sure not eager to deconstruct the system.

  14. Chris says:

    $750 a month for my family, and $1000 deductible (we’re non smokers). it’s outrageous. and we had to switch carriers last year because our rate was going to $1000 a month.

  15. Cennydd says:

    The travesty of it all is that the pharamceutical industry hasn’t done more to clamp a lid on the ever-increasing costs of research. In other words, self-regulation doesn’t work, and it’s time for Congress to step in and take action. Will they? It’s doubtful as long as the pharmaceutical/HMO lobbyists have any influence in Washington, and as long as they do, there’ll be no progress.

    What worries me is the effect this will have on young families. California has the Healthy Families program for lower-income children, while their parents are often without coverage…….and it’s necessary for those parents to pay extremely high premiums or go without……praying that they don’t become seriously ill!

  16. Bob (aka BobbyJim) says:

    My wife and I are self-employed and have private insurance. It is not cheap, and our doctor works with us. However, I do not think nationalized health coverage is the answer. If you want to sample nationalized health care ….. then join the military and try that version on for a while 😉 That should cure your itch for a few years 🙂 (Humor folks, just humor. Don’t get carried away.)

  17. RoyIII says:

    I can’t understand why some insist on keeping the system as it is when the status quo works against their health and security long term.

  18. jamesk says:

    Cennydd, I really am not interested in being an apologist for big Pharma, so call me on it if I come across as biased.

    To begin with, I really think that all of the direct advertisement directly drives up costs, and this likely could be curtailed somewhat.
    I occasionally am an investigator on drug trials, mostly antibiotics and such, and you would not believe the level of rigor needed. sometimes $10-20,000 per subject for a fairly simple study. This is COST. (The reason I’m involved in contract research of this sort is that if I can keep several trials going at one time, I can manage to keep one nurse employed and use whatever spare time she has to help with unfunded research of my own. It’s really not a cash cow.) Despite these high costs, I actually think we miss a lot. Think about the recent cox-2 inhibitor and Phen-phen debacles. We (the US) tried recently to relax standards and accept European approvals as enough, but there were a number of serious oversights that resulted in drugs being withdrawn. In the meantime, every time a screwup like that happens, the John Kerry types are salivating while holding a multibillion dollar class action suit.
    I suppose we could accept that drugs just won’t be as safe, but I really don’t want to give my children something that isn’t as safe as possible. Moreover, the rest of the world benefits from this state of affairs in that the entire drug supply gets better at our expense.
    I really don’t know the answer.

  19. Bernini says:

    I do not vote for Democrats, but as a self-employed individual I can honestly say that health insurance scares the crap out of me. I never hear anything good about it, whether you work for a major corporation or not. Damned if you’re self-employed, damned if you’re not.

  20. Kaye says:

    I think you are entirely right, (James #13) in what you say abut government insurance. All we have to do is look at our wounded veterans and see the kind of care they don’t get proper care. Of all People, those who put their lives on the line for our country to remain free should get the best care possible. The problem is they don’t because the government doesn’t care. Government employees have their own government paid for life insurance.
    Another factor is that Lawyers make up the majority of government as well as control the pharmaceutical industry. Throw in the lobbyists again mostly lawyers and we the people don’t stand a chance.
    Personally I would love to see term limit’s in ALL areas of government. The good old boys/girls club would certainly lose it’s effectiveness.
    One other area we need to hold our officials to is the “pork” added to bills and the amount of money various elected officials receive. These officials up for election should be held accountable in detail the amounts of pork they attached to bills and the dollars from lobbyists in detail with names and company they represent. This should apply to all government officials from the mayor of a small town to the President.
    I’m remind of those words that form the the foundation of our country:”We the people of these united states in order to form a more perfect union….”

  21. Cennydd says:

    Since I’m a retired USAF NCO (100% disabled, service-connected), I’m also a government employee (although not always perceived as such) receiving disability benefits……and believe me, it is NOT the desirable way in which to qualify for those benefits. I don’t recommend it. It’s the military retirement that no one in their right mind would want!

    There is no panacea in receiving government medical retirement benefits, and I have to agree that returning veterans don’t always receive the quality treatment that they so badly need. The biggest reason that they don’t is due to the fact that Congress consistently has balked at providing the necessary funding for the Veterans’ Administration’s medical programs, and as a result, veterans usually blame the VA for the shortcomings.

    I am a Life Member of the Disabled American Veterans, and we are, and have always been, at the forefront in urging Congress to provide the necessary funding. I have always urged citizens to make their views known to Congress on the issue of medical care for ALL of our citizens, and to demand that costs be brought under control.

    Government-provided insurance isn’t the answer for everyone, but government-ENSURED insurance would be a step in the right direction by providing that employers must offer their employees a choice of affordable plans.

  22. DonGander says:

    I guess I just might die of something some day. By God’s grace I have lived as long as I have. By that same grace He will take me home.

    I’ve not had much time to think about insurance.

  23. jamesk says:

    Cennydd, I agree wholeheartedly both as a consumer and as a provider both in the VA system and through TRI-CARE (jeez you wanna talk about REALLY BAD insurance) providing subspecialty care to active duty as well as dependents. It would be GREAT if the nearly 35% of patients that I treat who are unfunded had some form of insurance (I don’t even ask if they can pay, I just do it and pick up afterwards). But I’ll tell you what, If it was the status quo or EVERYONE, including me, having benefits as bad as AD servicemen who have to go out of network, often for combat related injuries, I’d much rather keep things as they are.

  24. Cennydd says:

    Agreed…….though I do sympathize with those who have no insurance because they can’t afford it. And thank you for helping those who need your help. You’re a blessing!

  25. Cennydd says:

    And yeah, I know all about Tri-Care for Life…….that’s why I won’t use it if I can help it!

  26. Now Orthodox says:

    My wife and I have an HSA. Our deductible is $10,000. Our premium is $287 / month. We can put in $6450 per year in the HSA tax deductible. We pay our medical expenses out of the account. With the insurance card we don’t pay full rates at the doctor’s or the pharmacy.

    My solution would be require insurers in each state to accept “bad risk” patients just as auto insurers are required to do. That would raise rates some but enable everyone to get insured. Secondly, reform the tort laws by capping damages on suits. Hey I’m sorry, but if you smoked for 40 years, you shouldn’t get millions of dollars for your stupidity. I know that some things like Vioxx slip through the cracks, but everyone is not worth tens of millions of dollars. Just as shop lifters drive up the price of retail goods, lawsuits drive up the cost for doctors and drugs. Just my opinion!
    Peace,
    Barry

  27. John Wilkins says:

    Sidney is right. If you want insurance, you can afford it.

    Good insurance? Not really. Then you also need to pay a lawyer. Even those of us who have excellent insurance (I’m single and pay $600 a month….) still have to do battle for tests much of the time. One parishioner just said he’s stopped fighting because it is such a hassle.

    What would be nice is insurance companies who defended the patient.

    As far as smokers go, studies show that they tend to die earlier anyway. The idea that they are a further burden on the system should be interrogated.

    The issue is really is whether as a country we think we should care for each other. Or whether we suppose profiteers will do that better than those not looking for a profit.

  28. Cennydd says:

    I have no use for those who profit from the misery of others. No decent person should!

  29. ann r says:

    When my children were young, no one had health insurance. It wasn’t even thought of. And medical care was much, much less expensive. Office visits for my kids were usually $10. Hospital room costs ran $25 a day. That was only 40 years ago. The insurance doctors and hospitals now must carry is one major cause of increased cost. My daughter is a dentist, and her insurance costs are enormous. There are Christian groups that pool resources in a co-op fashion. They help one another out with their major bills. In my county lots of folks don’t have health insurance and the community often helps out: spaghetti feeds, bake sales, etc. The local appliance repairman needed hip surgery, and it was entirely paid for by local donations. If my husband and I had put in savings all the money we have paid out for insurance over the years, we sure wouldn’t need insurance.

  30. robroy says:

    Someone mentioned the pharmaceutical industry. I just found out that advertising cost more than research. The industry has only been allowed direct consumer advertising in the past ten years and it is now a bigger budget item then research! Disgraceful. The cost to benefit ratio for Viagra ads, etc, is essentially infinity to nil. That cost is passed on to all of us, however. The industry argues that it is educational. B.S. Have them fund some public service announcements at a hundredth of the cost.

  31. Yooper says:

    I am self employed and I have 60 employees. Everyone is insured whether they like it or not in my Practice ( I am a veterinarian). My feeling is I will not be responsible for someone in my employment lying in a hospital bed w/o insurance. I have several employees who want me to give them cash instead of insurance and I tell thwm it is not company policy,ie my policy. Yes it is expensive. But we are seeing very important breakthroughs in medicine that will significantly lower the overall cost of insuring the older generation(me included). The recent discovery of a cure for Altzeimers disease that will effectively put most of all the nursing homes that care for these unfortunate people out of business. The important thing is the cost. Would you rather pay 10,000 a year for medication that allows you to keep your sanity or say 300-400,000 to warehouse these patients indefitinely. Another example is a leukemia that my wife had 6 years ago. Her treatment was close to 750,000. She lived. But the greatest thing to come out of her treatment was that the survival rate for her type of leukemia went from 5% to 95% because now the patients just take the new experimental drug she took that cost 48,00 a year. She was cured as are all of the subsequent patients that have her type of leukemia. 750,000 vs 48,00 and death vs life. Thats what the threshold holds for us. Costs will come down , medications may be expensive but the alternative is worse and more expensive.

  32. Echolord says:

    Personally, I’m much more in favor of health savings accounts, and paying out of pocket expenses. Medical insurance, isn’t really treated as insurance anymore, what other insurance vehicle is even thought in the same context. When little Johnny next door throws his baseball through your plate glass window, do we immediately call up our home owner’s insurance claims department? Yet if we get a winter common cold, we don’t feel any hesitancy in demanding our health insurer foot the bill. We as a nation have become addicted to the idea that we shouldn’t pay for even our minor ailments, its no wonder health insurance is so expensive, were the insurance roles reversed, our home owner’s insurance would be outrageously priced.

    On the other hand, it is irresponsible and neglectful of our families, to not have a catastrophic health insurance program of some kind. I too have walked down the self-employed path, however I chose to only purchase insurance for what really threatened my family’s future finacial wellbeing. I joined the National Association of the Self-Employed, who have a group like insurance vehicle from Mega-Life and Health, which cost me approximately $380 ea month for my family of 5. The higher deductible of $10,000, was a reasonable trade, for not paying $800-900 ea month for someone else to pay for my minor aches and pains.

  33. Dave B says:

    For Folks with trouble paying for medication many drug companies have programs to help. My wife just finished nursing school and some of her research involved this subject. Many drug companies have internet acess to help with this.

  34. Sarah1 says:

    RE: “The issue is really is whether as a country we think we should care for each other.”

    No, the issues is really whether the citizens of that country wish for the loving care of the State. Is the State the [i]method[/i] that we wish to use to “care for each other”?

    My answer is no.

    JW’s answer is — of course — yes.

  35. Jeremy Bonner says:

    #29 touches on an interesting point. During the 1940s, one of the big debates was over whether health insurance should be based on employment or some other criterion. Given the then assumption that everyone would be working for a large corporation in the near future, it is perhaps unsurprising that employer-based systems won out.

    Today there are fewer large employers and they employ proportionately fewer of us. Perhaps the time has come for genuinely nonprofit health cooperatives based either on geographic or non-geographic principles that are locally accountable (boards drawn from the local community) but linked with their counterparts across the nation so that acute/expensive cases can still be treated by specialist facilities.

    This might be something the churches could consider taking on. After all, most American health care systems were originally launched as religious undertakings.

  36. Clueless says:

    Neither the church, nor anybody else can “take on healthcare” until the liability system is fixed. Sick and dying people are not “profitable”. They never were. At one time there was enough money floating around the system from treating healthy people with head colds to fund elderly people with cancer and strokes. This is no longer true. Thus, medicare and medicaid pays less than office overhead, and physicians and hospitals overcharge the self insured and those with private insurance. (They are _required_ by law to overcharge the self insured and uninsured, if they offer them free care or medicaid rates this is known as “insurance fraud” as they are no longer giving the government the lowest rate).

    Americans expect that, even if they are receiving charity (which is what medicare and medicaid amount to) they should receive the absolute best of everything, and expect to sue if their life expectancy drops from 90 to 88 if they don’t receive their pacemaker or clot busting agents, Americans _get_ the best of everything.

    Unfortunately the best of everything costs money. Right now this is being provided by “unfunded mandates”. This says that anybody who comes into the ER, whether illegal, uninsured, obnoxious, or criminal gets the best of everything, and the hospital and the doctor pays as long as they are in business (collecting as best they can from the paying patients to remain in business). If they don’t they are not only commiting criminal malpractice but are unethically “abandoning their patients”.

    If the church were to take this on, then the church would be DESTROYED by the unfunded mandates, and while being destroyed, would be roundly reviled by all Americans who will sue, and demonstrate because the church has ABANDONED them in their hour of need by being unable to keep up with their ever rising expectations.

    I support univeral government health care despite the fact that health care quality will fall like a stone, and despite the fact that there will be implicit rationing (it will be called “Evidence Based Medicine” or “Quality Benchmarks” not “rationing”) because the ONLY entity that can take on the health care system is the government. This is because they have SOVEREIGN IMMUNITY and can laugh off all suits.

  37. robroy says:

    One of ER doc buddies told me that this story: He was working one day and a patient was brought in by his wife in a late model cadillac. The patient was having crushing substernal chest pain. The patient whispered to the the ER doc, “No, I don’t have any insurance, but if you don’t give me the best care, I am going to sue your pants off!”

  38. Jim the Puritan says:

    I think one of the biggest absurdities is that my health insurance will not cover the cost of a routine yearly physical. You have to be sick to get covered for a doctor’s visit. The next step is that my physician (actually my wife’s doctor, since mine retired and I’ve never found another that would take me on my own; most doctors here now will not take new patients), will not treat a patient unless there is insurance coverage. The nurse tells me to make something up so that he can take a look at me and then can charge it to the insurance company. I say I’m not going to lie. I say I’m even willing to write him my personal check right then and there for the cost of the visit or they can put it on a charge card. Nope, no go. So I can’t get a regular checkup. Talk about misplaced priorities–the system waits till you are sick, rather than catching something early.

  39. Jim the Puritan says:

    37–Another such story. Many years ago my friend, a lawyer, was hit by a drunk driver while he was helping assist moving another car that had stalled on the roadway. He was very badly injured, being crushed between the drunk’s car and the stalled car. They were wheeling him into emergency surgery; of course, everyone had masks on so he couldn’t tell who was who. The last thing he remembers is someone (probably the anesthesiologist) saying in an evil-sounding voice, “so you’re a lawyer, huh? heh, heh, heh, heh . . . .” and then everything went black as they gave him the gas. No, we lawyers are not all bad guys, and in fact my friend is now, many years later, a trustee of that hospital.

  40. John Wilkins says:

    Sarah – you seem to think “the state” is a monolithic entity. Why did you use “the state” rather than, say “our democracy?”
    Empirically, the state is helpful in many ways. In fact, it goes back to Augustine who noted that we are sinners – and for this reason we simply don’t tend to give what is required if we want to live in Christian brotherhood.

    Individualism is, possibly, a sin because it renders the system of cooperation (say within capitalism or regulation) invisible.

    I suppose if people werent’ sinners, big companies would try to push around small companies. In my world, there are Enrons and MCIs and bad mortgage brokers. People try to break the law. For this reason, we – as a public – support institutions that mediate between others. Likewise, things like clean air and water – not profitable things, mind you – require a policeman. Perhaps you don’t need police where you are. but not in my neck of the woods. I think we should pay them. You might not want to pay them, because they are… the state.

    The state, through NASA and the military is a fairly big source of give back to the country. The military, for example, is an important part of the culture. It forced integration. It supports lots of communities. It is where lots of investment in technology gets made. Many universities are subsidized through the military. Personally, I think having a military bigger than all the other militaries in the world combined, just makes taxpayers angry because most people don’t see the benefit of paying taxes. We could have closed the science gap or given health care to pretty much everyone for 50 years with the amount we’re sending to war profiteers. Perhaps a few thousand are safer in this country because of the impact that terrorism might have, but I think millions of people would benefit from reliable health care.

    You seem to think there is an either / or involved. I don’t see it. I do think that people imitate the institutions around them. Institutions that only value making money will form people who are only interested in making money. those that are involved in mission will form people who do mission.

    Sarah, we are in a democracy. I’m proud of what this country has done – as a shared enterprise. There was a time when people cared about the country and used it to serve the public good through the institution that is the sole representative of all its citizens. If you think I suppose the state is the ONLY institution of caring, you’ve got me pegged for someone else. But its pretty clear that Corporations don’t have people in their interest.

    In fact, as an investor, I would oppose a health insurance company taking the claims of patients too seriously. If they weren’t screwing patients over, they wouldn’t be doing their job. and if there isn’t a regulator, they should try to screw with people as much as they can. Nobody’s watching after all.

    My dividends would be at stake.

  41. Clueless says:

    “I think one of the biggest absurdities is that my health insurance will not cover the cost of a routine yearly physical. You have to be sick to get covered for a doctor’s visit.”

    The idea that patients have that every visit should be covered is part of the reason health care is so expensive. What do you think your car insurance premium would be if oil changes, tires, gasoline and routine maintenance were covered? Now suppose that people regularly sued their service centers if their tires (which they failed to keep inflated) went flat? What would your insurance premium be then?

    “The next step is that my physician (actually my wife’s doctor, since mine retired and I’ve never found another that would take me on my own; most doctors here now will not take new patients), will not treat a patient unless there is insurance coverage. The nurse tells me to make something up so that he can take a look at me and then can charge it to the insurance company. I say I’m not going to lie. I say I’m even willing to write him my personal check right then and there for the cost of the visit or they can put it on a charge card. ”

    Guess what? You just asked your doctor to commit fraud. It is not permited for a physician to take money from a patient if he “just wants to have a look at him”.

    Going after “insurance fraud” like seeing people for free, or spending an hour talking to a patient’s mother about the terminal disease her kid might have without the kid present is considered fraud. (You can’t bill the patient for this, and you can’t not charge the patient because if you do, then you are not giving the government your lowest price, like you promised to do when you chose to accept Medicare/Medicaid. Thus, if you feel it is necessary, you need to do so but not provide any paper trail that let people realize that you actually spent a couple of hours taking care of somebody for free.

  42. Jim the Puritan says:

    #41–I’m not sure whether you are being cynical or serious. Are you saying it is a good thing that doctors are no longer permitted to give annual physicals that could catch a medical problem early, when it can be easily treated, and instead wait until a patient is inflicted with, say, a now unstoppable malignant tumor, which will end up costing the insurance system hundreds of thousands of dollars to treat with death still being the result?

    Sounds like a pretty messed up system to me.

  43. Clueless says:

    I’m being serious. I think that just as responsible car owners change their oil, inspect their tires, and do routine maintenance and expect to pay for it, responsible citizens should do the same for their health maintenance.

    The cheapest health care system would include a 5,000 dollar deductable and catastrophic care coverage, with all losses due to medical advice/surgeries going through out of court review, just like if folks are unhappy with their broker’s advice on stocks.

    Then, when folks bump their heads, they can decide for themselves whether they want to get the 1000 dollar CT scan in order to cover the one in one thousand chance that they might have a subdural, so as to “catch a subdural early”. Right now, anybody going to the ER with a bumped head and no loss of consciousness automatically gets the CT scan because first, it is “only” insurance who pays, and secondly because it will be the physician who gets sued, on the one in a thousand chance that the patient does have a subdural, not the insurance company or the patient who wants to save money.

    I’m being serious. Yes, subdurals are best treated early. Yes, tumors are best treated early. However, it costs Society more to do millions of screening examinations than to deal with the unstoppable malignant tumor that is usually in a patient who both older, and no longer paying serious taxes, and who is on medicare and therfore is not paying his fair share anyway (i.e. does not have private insurance).

    How much is it appropriate that Society take from the young, healthy and from future generations in order to improve the life expectancy and wellbeing of the old and the frail?

    Right now, the young are getting a pretty raw deal between both Social Security and Medicare. At what point do we Boomers (and I’m one of them) say, “I think my turn is over, and it’s time for somebody else to have a turn?”

    Make no mistake, I will lose money and get worse care when universal health care comes in. However I think that not saddling future generations with debt is also a “Social Justice” thing.

  44. Jim the Puritan says:

    I’m only talking about a routine yearly physical, with blood work and urine sample, something that used to be an accepted part of medical practice.

  45. Clueless says:

    #44 That’s what I’m talking about too. The annual physical was not an “accepted part of medical practice” back when doctor visits cost a few dollars and patients paid up front.

  46. David Keller says:

    Clueless, a couple of thoughts: 1. Jiffy Lube doesn’t give illegal aliens or “indegents” free oil changes and expect me to make up the difference when I pay for mine. 2. It makes no sense for an insurer to pay for an amputation of a diabetic’s leg or cover their blindness, kidney failure etc., yet refuse to provide preventive services, such as membership to a gym or dietary counselling (at a fraction of the cost). I am 58, in good health and run at least 4 miles a day. Guess what Blue Cross will say if I ask them to pay my $480 annual gym membership. Our health care resources are totally misalloacated.

  47. jamesk says:

    There is nothing fraudulent about a patient paying to see a doctor as long as it is above board. What IS fraudulent is if a doctor charges a patient either more than the payor has agreed to pay for a covered service, or charging a patient for preference, that is, paying more for special treatment when the service would otherwise be covered. If both the insured patient and the provider know upfront that the provider is providing an uncovered service, the patient gets the bill and everyone is happy. Plastic surgeons everywhere take Visa as well as Medicare.

  48. Clueless says:

    #46

    The United States requires that illegal aliens, people injured while commiting a crime (indigent drunk drivers) be seen in Emergency rooms whether or not they can pay. If they require consultation by private specialists that specialist needs to come in and see the patient whether or not they can pay. The illegal alien or the indigent drunk driver retains his right to sue all providers if his neck trauma sustained during the alcohol fueled crash fails to improve, even if the providers did everything right. Failure to come in to see the patient promptly is punishable by a minimum 50,000 fine per occurance levied on both the hospital and the physician, together in addition to any criminal or civil charges for patient “abandonment”.

    This is the main reason that there are no pediatric subspecialists in my local area, any kid with a subdural either is airlifted 150 miles away, or dies in transit. The neurosurgeons in town focus on back surgery and say they don’t have the skills to take care of children. (And if you don’t see kids on a regular basis, you will definately lose those skills so they do not lie).

    As to failure to provide preventive services, again, why does your insurer need to pay for prevention? Does she pay for your oil changes? What I think would make more sense than insurers paying for golf lessons, is for insurers to make folks who smoke, have sexually transmitted diseases, or who are fat pay a very much higher premium than folks who look after themselves, the same way that folks with a bunch of speeding tickets pay higher premiums than those who drive safely.

    Why is it that Americans can’t go eat healthily, and run around the block without asking future generations to put it on their credit cards? Somebody does pay for all this you know. Right now it is the folks who will inherit our national debt.

  49. Clueless says:

    7. jamesk wrote: “There is nothing fraudulent about a patient paying to see a doctor as long as it is above board. What IS fraudulent is if a doctor charges a patient either more than the payor has agreed to pay for a covered service, or charging a patient for preference, that is, paying more for special treatment when the service would otherwise be covered.”

    Not quite. Most insurance contracts have a statement in there saying that the physician agrees not to ask for any additional payment.

    Thus, yesterday I spent two hours talking to a patient whom I diagnosed with a terminal disease, who probably is one of the wealthiest people in my state. Medicare paid the same amount that it would have paid had I spent 20 minutes with the patient, and of course one cannot charge extra, even though the patient would have paid the amount without question. It is fraud to suggest that the 100 minutes be compensated.

    Similarly, I have often spent several hours speaking to the parents of Medicaid kids with learning disorders. These are treatable entities, and I take my job seriously. If the kid is throwing a tantrum, while I am trying to speak to the parent about something important I do, on occasion have the parent come back after hours so I can explain it to them. However one can’t bill if the child is not present, and anyway even if one did, one scarcely collects the amount of transcription and collection expenses anyway. It is fraud to bill for education of a parent. That is not considered “direct patient care” which is the only thing one can bill for.

    If both the insured patient and the provider know upfront that the provider is providing an uncovered service, the patient gets the bill and everyone is happy. Plastic surgeons everywhere take Visa as well as Medicare.

  50. jamesk says:

    48, not to be inflammatory, but, speaking as one of those subspecialists (who DOES come in to treat whomever needs it) it is expensive, I assume liability without hope of remuneration, and sometimes it pisses me off, but guess what: Yes, it screws up my family life and I’ll probably die young from all the stress but I’m not in the poorhouse, I have more grateful patients than you can shake a stick at, and I feel like it’s my responsibility to try to provide my patients with the best care possible, keeping the decalogue and golden rule in mind. If it sticks in a doc’s craw too much, he should get a gig in a salaried or non-call specialty. Plenty of them out there.

  51. Clueless says:

    Oh delete that last paragraph. That was from jamesk’s post. Neurologists do not have the luxury of simply telling our patients that they have an “uncovered service”.

  52. Jim the Puritan says:

    [blockquote]#44 That’s what I’m talking about too. The annual physical was not an “accepted part of medical practice” back when doctor visits cost a few dollars and patients paid up front. [/blockquote]

    Which is why I said in my first post that I was willing to pay for it out of my own pocket, rather than fake being sick so he could then give me a checkup and then charge it to insurance (that is what I think would be dishonest). But apparently my paying directly outside of the insurance system either violates the agreements the doctor has with the insurance companies, or he has concluded the hassle and paperwork of getting paid directly by a patient rather than through insurers is not worth it.

  53. jamesk says:

    I’d be happy to argue the minutiae of CPT coding with you in a different forum, but you know as well as I do that the amount of time spent with a patient does affect the level of billing, you just have to meet the documentation requirements which often make it not worth the effort. a level 2 visit which in my neck of the woods bills 62 bucks for medicare, could be upcoded to a level 4 ($211) with the addition of a ROS, 7 exam components, the documentation of “extensive counselling in excess of 30 min” and a “decision for surgery”. Usually, though, I just eat the extra E&M;because the documentation time is better spent doing something productive.

  54. Clueless says:

    I have lots of grateful patients and I come in too. (My call schedule has improved, it is now every 3rd, not every other night). I also am not in the poorhouse either. I too provide my patients with the best care possible, and I still enjoy medicine.

    However it is sticking in my craw as you put it. The fact that call is every third, and is usually busy also sticks in my craw, and seriously impacts my family. Yes, I could get a noncall position, lots of them out there as you say. Further, if I did a sleep medicine only position, it would be quite lucrative as well as giving me lots of free time. The reason that I stay is that I am the only person who sees kids in 150 miles. When I leave, there will be children who will die. I will not know their names, and neither they, nor their parents will blame me (they will be too busy suing whomever is left) however they will be dead anyway and to some degree it will be because I abandoned my post.

    And so I stay. I’m not even bitter. I still like medicine. Just don’t expect me to ooze sympathy because somebody else thinks medicine is too expensive and should cover their gym membership.

  55. jamesk says:

    52, if You’re in an HMO that may be the case depending on the contract your pcp has because in essence, the hmo pays a flat fee for whatever care you require in during the contract period. In that case, all you gotta do is go outside your network and get someone else to do it. Trust me, an internist is going to fall all over himself to see someone who actually wants to pay cash on the barrelhead.

  56. ann r says:

    Those like John W. who favor federal health insurance should look at the results of the current federal health insurance, namely Medicare. The elderly are brainwashed into thinking they have to enroll in Medicare. Medicare does not cover office overhead for any type of visit. Medicare is causing rural hospitals all over America to go broke. Not only does Medicare not cover the cost of care, but at the end of the year Medicare will review its payouts, and decide “Oh, here we paid you too much” and ask for the money back. Medicare is a very bad deal for hospitals. On top of that, the cost of documentation for Medicare and other insurances require hospitals to either have a huge billing department, or hire billing out to a private firm that may or may not actually bill properly within Medicare’s time limits. On top of that, I know one woman who died because Medicare would not pay for the nursing she needed to prevent post-op infection, and would not allow the husband to pay for it out of pocket. We are over 65 and will never, that is NEVER, enroll for Medicare, nor any other state run program. I think insurance is more of a problem than big pharma. Catastrophic is worth carrying, but nothing else.

  57. Dave B says:

    In the quick read over of these posts the one thing that is missing is a discussion of WHY heath insurance came into being,and it wasn’t to provide health care! Blue Cross and Blue Shield provided funding to support hospitals, NOT to provide health care. This means no preventative medical care was funded, visits to Docs was not funded etc, but emergency care was funded since it happened in the Hospital. I think a few simple reforms like a patient compensation program similer to employee comp with the Doc, patient, hospital paying the premium for untoward out comes could reduce tort a lot. Arbitration for disputed settlements. Health insurance for health care NOT for hospital income. Premiums based on lifestyle, health and preventative care. Underwriting for high risk cases. Broad based group coverage to limit clustering of high risk patients. Just a few of my thoughts. I am afraid national universal health care will lead to rationing and a bunch of ethical issues. The other sad part is that we spend most of our health care dollars on the last few years of our lives. Maybe a little realty and preperation for our demise might also help reduce our health care expendatures.

  58. jamesk says:

    It’s actually worse than that Dave. Last I checked it was close to 50% of Medicare payments were made in the last 30 DAYS of life.

  59. Clueless says:

    I understand that more than half of all payments are made in the last 6 months of life. Since we will all of us die eventually, this is why eating right, going to the gym, and getting an annual physical will not bring down the cost of health care. In fact it will only increase the cost of health care, by ensuring that the individual in question will die at the age of 93 with a protracted course of multi-organ failure after having not paid taxes for almost thirty years, instead of dying at 65 of a sudden heart attack the day he qualified for Social Security. That is not to say that doing these things are not a good idea, I simply point out that however much these virtues may improve an individual’s life expectency and health, it will not improve society’s fiscal position. Indeed, from a fiscal point of view, we should probably encourage people to smoke cigarettes, over eat, and thus die shortly after (or before) they begin to collect Social Security.

    What other countries do is ration. In England, over the age of 55 you do not get dialysis. Or elective spine surgery. No European country gives as much health care to octogenarians as we do. There is no other country in the world where 90 year olds routinely get pacemakers and cardiac stints.

    Again, I do not advocate rationing. I simply point out that right now we are rationing, only irrationally. Children with asthma and seizures don’t qualify for subsidized health care; 90 year olds with cancer are subsidized. An uninsured adult with appendicitis may fail to seek care until he dies of septic shock. An 88 year old smoker will qualify for anual chest xrays, and then whatever chemotherapies and surgeries may be helpful. Society cannot function when the most productive individuals are so heavily burdened in order to provide benefits to those least productive. Personally, I would favor explicit rationing in a universal health care system. This seems to be to be more honest than the rationing by allocation, and hassling of providers, while encouraging patients to believe that if only “fraud and abuse” were prevented, money would fall from the skies, and they would be able to afford all the preventive maintenance and gym memberships they desire at no cost at all.

  60. ann r says:

    Clueless, the trouble is, as I am sure you are well aware, that age is not necessarily a suitable criterion for when those final months will be. I lost a whole bunch of my friends before age 60 from cancer. In my area a lot of the community service volunteer jobs that working folks can’t possibly take on are very capably done by folks in their 70s and 80s. Chronic disease is another possible criterion, and in some places that means an otherwise healthy person with Parkinson’s or asthma, or a heart murmur would not be able to receive surgery for appendicitis, or female problems, etc. Oregon has a little list of society offenders who never will be missed, folks who don’t qualify for care. So does the UK. These are folks who may be wage earners, caring for families, etc. Doesn’t matter. They’re on the list. Then there is the whole picture of who decides quality of life issues. Think of Joni Erikatada, or however her name is spelled—pretty much paralyzed but a very effective missionary. And unless the problem of keeping rural hospitals open is solved, the whole question will be moot for large areas of the country.

  61. Clueless says:

    Oh I agree. Nor have I any wish to be “chooser of the slain”. I have already decided to retrain as a high school teacher when rationing comes in. But it will come in, sooner under Hillarycare, but eventually anyway. But as I noted, we already ration. Right now, the folks on the short end are children, and the working poor.

  62. jamesk says:

    60, would that all we had to wait for was a short, sharp shock, Unfortunately, it’s more along the lines of a life long lock.

    Ah, willow…