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Which comes first: Patients or principles?


It's a doctor's obligation to accept insurance, no matter what he thinks of the system, this author argues.


A Medical Economics Web Exclusive

Which comes first: Patients or principles?

It’s a doctor’s obligation to accept insurance, no matter what he thinks of the system, this author argues.

By Max Burger, MD
Family Physician/Medford, NJ

I never thought I’d argue with another family physician about the quality of patient care. Yet there he was, sitting at the same table at a dinner, telling me I was immoral to practice as I did.

What had I done wrong in his eyes? I saw my patients on their terms and accepted whatever insurance they came with–HMOs, PPOs, traditional indemnity, Medicare, Medicaid, workers’ compensation, automobile–or cash. I saw those who couldn’t pay and worked out arrangements without denying them care. I dealt with the reality of the marketplace. Did I like it? No, but neither did my patients.

My dinner partner refused to accept insurance and would take only cash. If patients couldn’t pay, he saw them anyway. He turned away people who wanted him to take their insurance. He worked in two offices and in a jail to supplement his income–yet he railed against colleagues who wouldn’t follow his lead.

I started my career working in a group-model HMO. I knew my patients, and they knew me. They understood the limitations of their insurance, but knew they could see the same primary care doctor and specialists when needed. Most realized that our relationship was built on trust and the HMO was the means of maintaining that relationship. I knew the plan’s administrative structure and how to get what my patients needed.

Then the HMO failed. It wasn’t the doctors’ fault–just the result of bad business decisions. I had seen it coming and gotten out.

In practice for myself, I discovered the chaos that exists in American health care. I can’t change the system by myself–certainly not by refusing to accept third-party payments. I can practice in a moral way and meet my responsibility to patients only by being as available as I can.

The only thing that’s immoral in American health care is the fact that we’re one of the few developed countries that don’t provide universal access to care. Few politicians in this country dare to commit themselves to securing care for everyone or controlling the marketplace mentality that searches for health care at the lowest price.

I understand my dinner partner’s anger at third parties, but I am not a collaborator with the enemy. I work with what we have available. He has put his principles above his responsibility and called it morality.


Max Burger. Which comes first: Patients or principles?.

Medical Economics


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