Of Wealth, Health, and Cash-Only Practices

Ah, take the Cash, and let the Credit Go.

Edward Fitzgerald (1808-1883), The Rubaiyat of Omar Khayyam

Cash-payment is not the sole nexus of man with man.

Thomas Carlyle (1795-1881), Past and Present

November 24, 2012 -  In the rarified world of social welfare reform,  it is anathema to use the words  “health,” and “cash” in one sentence.  It is one or the other. “Cash” smells of “cold-hard cash,”  “cash-and-carry.”  It distracts from the world of human needs and the social determinants of health.

Instead what people deserve, say advocates of the all-encompassing social welfare state, are conditions in which all people can be healthy, including equal opportunities for “education, housing, employment, living wages, access to health care, access to healthy foods and green spaces, occupational safety, hopefulness, and freedom from racism, classism, sexism, and other forms of exclusion, marginalization, and discrimination based on social status.” (Wilkinson, R, Marmot M., “Social Dterminants of Health – The Solid Facts, 2^nd Edition, Copenhagen: The World Health Organization, Regional Office for Europe, 2003).  Overly generous social welfare programs in socialist countries with aging populations and low birth rates are a huge factor in bringing their  economies of these countries to their knees.

No mention in the WHO report is made of “profit,” “prosperity,” and “economic growth,” as the engines that make possible  this utopian state of affairs.   And no mention is made either in this week's New England Journal of Medicine (Jennifer K. Cheng, MD, “Confronting the Social Determinants of Health – Obesity, Neglect, and Inequity, November 22, 2012) of these factors.   Instead the latter article ends with a quote from Theodore Roosevelt, “The welfare of each of us is dependent fundamentally upon the welfare of all of .”

While one can hardly disagree with any of these sentiments,   the fact remains that all of us, including physicians,  have to pay our bills.  In the case of physicians, we somehow have to compensate for 15 years spend in education and training outside the economic mainstream,  paying for crushing medical school debts in the neighborhood of $150,000 to $200,000, the cost of malpractice insurance and complying with onerous government regulations.

One  physician response to the wealth and health problem,  i.e. cash-only practices,  is clearly brought out in  a yesterday New York Times piece (Paul Sullivan, “Wealth Mattters: Dealing with Doctors Who Take Cash Only,” November 23, 2012). 

The author describes the case of his 4 month old sleepless daughter.   A pediatrician drove an hour from his practice to see the little girl, spent an hour with the baby and her parents,  spent another hour returning to his practice, and submitted a bill of $650 not covered by insurance.  The insurance company would have paid $285.

The reporter says he and wife liked the doctor and the attention,  but he wondered what motivated doctors to go to cash-only practices,   The reasons  he cites are higher income, more time with patients,  lower overhead,  more patient satisfaction,  greater cash flow, and less third party harassment.    The problem for patients, of course, is more out-of-pocket cash, and increasing lack of affordability of  health care.

From 30,000 feet the problem  of cash-only and concierge practices,   which involves less than 10% of doctors but is growing,  is social reform versus economic reform, or put another way, health risks versus economic risks.

Stanford Owen, MD, an internist in Gulfport, Mississippi, who practices cash-only medicine, summed up the situation.  Dr. Owen says he is happy and feels that he is practicing family medicine the way his father and grandfather did. “Primary care is the least pay, the most work and the most responsibility,” he said. “Under this model, you can make a good living. You won’t get rich, but neither did the doctors in the 1960s.”

Tweet:  Primary care doctors are switching  to cash-only medicine to avoid low 3^rd party pay, to make more money, and spend more time with patients.