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The Way I See It: They won't let us treat the poor


People decry the plight of the uninsured, but we won't pay physicians enough to treat them, says the author, who had to close her inner-city practice.



They won't let us treat the poor

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People decry the plight of the uninsured, but we won't pay physicians enough to treat them, says the author, who had to close her inner-city practice.

By Susan Hershberg Adelman, MD
Pediatric Surgeon/ Southfeild, MI

When I finished my pediatric surgery residency in 1974, I opened an office where I thought I would be most needed—the inner city of Detroit. Later, I opened another office in nearby Dearborn. Last year, I closed both. They simply lost too much money.

I was not alone. Many fine physicians have quit after suffering through years of practically no income. Physicians have been laid off from Henry Ford Hospital, the Detroit Medical Center, and a staff model HMO. Fifteen out of 39 Detroit area hospitals have closed in the last 25 years. Only two city clinics remain open. You can count the number of pediatricians left in private practice in Detroit on two hands, and the obstetricians on one.

These days we keep hearing about our most vulnerable populations and how important it is to train a diverse group of doctors to take care of them. But nobody is talking about how we must help these safety-net practices keep their doors open.

Why my practice couldn't make it

My practice grew to fill the needs of the surrounding population. Patients saw me when they came in, not a rotating resident. I learned Arabic. I knew my patients' culture, their families, the holidays when they fast. One child sent to me for possible appendicitis was spared an unnecessary operation because I knew it was Ramadan, and I realized that fasting had made him constipated.

What could have kept me going? It's simple: The practice, with its 70 percent Medicaid payer mix, had to stop hemorrhaging money. My yearly practice expenses averaged $220,000. To stay in practice, I reduced my salary down to almost nothing.

Some might say that the answer was to go into a group practice. But, actually, I already was. For the last eight years, I was on the faculty of a university that ran medical clinics, so I was in a group—only in an off-site location. But there was very little economy of scale. Each doctor's practice had to sit on its own bottom, so to speak. My department refused to continue subsidizing a money-losing practice, whatever my mission.

Medicaid in the state of Michigan pays 38 cents on every dollar billed. OmniCare Health Plan—a Detroit Medicaid HMO that went into reorganization—pays much less, between 13 and 17 cents on the dollar.

Where to get more money

Medicaid simply needs more money. The options are to raise taxes, change the system, or scrounge for other sources of revenue. Nobody expects a tax increase soon. If we change to a single payer system, Washington no doubt will franchise it out to the same private insurers that state Medicaid programs contract with today.

So we have to look for other sources of revenue. Here are a few ideas:

Now, Medicaid "disproportionate share" (DSH) funds go to hospitals with large numbers of uninsured or underinsured patients. If physician practices could receive DSH funds too, I feel sure my department would have regarded my mission with more warmth.

Where would this money come from? Commercial insurers could be required to contribute a percentage of their premiums into a state high-risk pool or a state reinsurance program.

Alternatively, private insurers could cover a minimum number of indigent patients. I know they will say this is an unfair tax, which will make them leave the market. But when it comes right down to it, they will just raise their premiums. That means you and I will pay more for our health care. In fact we're already paying much of this money to the government now, to cover the hidden costs of uncompensated care.

Patients who choose expensive health plans could be asked to pay an assessment. This would have the added advantage of discouraging wasteful over-insurance, and it would free up money for care of the poor.

There are other things that would help. Currently, professional liability insurance premiums for a general surgeon in Detroit are over $60,000 for coverage limits of $200,000 per episode and $600,000 per year. It would help a lot if the state covered professional liability for Medicaid patients. And insurers could reduce their rates proportionately.

The government needs to pay for all the services it mandates. Although I learned Arabic, not too many other doctors will. Perhaps someday translation services will be widely available by telephone. But right now, translators who come to the office are paid more than doctors. How can doctors pay them from stingy Medicaid fees?

Patient education classes could help patients and doctors. If insurers covered the service or offered patients discounts for attendance, primary care physicians could send patients to classes for common or chronic conditions. Nurses, doctors, and pharmacists could teach groups of patients about their constipation, low back pain, diabetes, asthma, or pregnancy. One-to-one patient instruction may be the gold standard, but it's costly and inefficient.

All hospitals must pay doctors for covering the emergency room, coronary care, neonatal intensive care, and other special units. Some hospitals are doing this today, but most still take all this physician time and stress for granted. If my hospital had paid me for those services, I would still be in practice today.

Finally, physician offices must begin doing all their pre-authorizations and billing inquiries online. It's expensive to ramp up, but it will save clerical time in the end. And any doctors who are in the office fewer than five days a week could save money with time-share offices.

At the moment, I'm writing, traveling, painting, and trying to decide what to do next. But my vulnerable patients have lost my services. The irony is that American doctors still go overseas as missionaries for the pleasure of giving old-fashioned care to the needy. We could be taking care of the needy right here. What the American public cannot do is wring its hands at the plight of our millions of uninsured and underinsured, then refuse to pay for the solution.

We could solve it—if we cared enough.


Susan Adelman. The Way I See It: They won't let us treat the poor. Medical Economics Dec. 5, 2003;80:79.

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