Wealth, Health, and Cash-Only Practices
take the Cash, and let the Credit Go.
Fitzgerald (1808-1883), The Rubaiyat of
is not the sole nexus of man with man.
Carlyle (1795-1881), Past and Present
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
“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, 2nd
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
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
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 3rd
party pay, to make more money, and spend more time with patients.
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