Dr. February is . . . Charity Doc

Picture of "Serious" Charity Doc

PART ONE

Another one of my favorite ER docs. Charity Doc knows how to inform, educate and express his views in an entertaining way that even non-medical types like me can understand and enjoy. Who else would think of using a butt pus analogy when explaining how he would go about solving our health care crisis? [Note to self: consider adding "in ten words or less" to some of the calendar doc questions].

In Part Two, Charity answers some of my more juicier questions.

Here's Part One of my interview with Charity Doc:

Q.1 WTF? Where have you been? What are you doing? Are you coming back? Why did you leave us hanging like that? you get the idea...

A.1 I haven't left medicine at all, I'm still taking care of patients but in a much different capacity. I abandoned my old gig because had to practice medicine on my own terms. I desperately needed to eliminate all of the bullshit that had made me miserable as an ER doc. I had to do it without the fears of litigation. I had to do it without the guilt of streeting a patient because he/she does not have health insurance or cannot afford what needs to be done. I was sick and tired of arguing with consultants night in and night out about admitting a patient to the hospital only to have them refuse. Or after forcing them to admit, they then turn around to discharge the patient the very following morning. Here's one such scenario…There's this homeless lady who comes into to the ED all time with right upper quadrant abdominal pain. I performed a bedside ultrasound on her during one of the early visits and found her to have gallstones. I did the study informally (because we had an ultrasound machine in the ED) so that she wouldn't have to incur the charges of an ultrasound. She never paid any of her hospital bills anyway so that, too, is a pointless discussion. In all of her visits she would get lab'ed up every time and discharged home for outpatient follow up when her labs came back normal without elevated liver function tests or pancreatic enzymes or leukocytosis. Bottom line, this lady has chronic cholecystitis and needed to have her gallbladder resected, but no damn surgeon in town would do it for her for free. She shows up to the clinics for follow up but gets turned away at the front desk after a negative wallet biopsy each time. This is after me getting personal verbal reassurance numerous times from different surgeons over the phone that they will see her in clinic. Several times, I begged the hospitalists to admit her to the hospital and consult the surgeon on call, which they did as a favor to me. But then she got streeted the following day each time after getting "plugged in" with social services to procure fundings from local resources and agencies for her "elective" surgery. This funding never materialized so she's still out there, over a year now, suffering miserable pain and waiting for the day when she gets really sick with a fever and her labs coming back abnormal to show that she has gallstone pancreatitis, cholangitis, or a perforated gall bag. It's despicable!

I also despised the hospital administrators to no end. They have no clinical experience or background whatsoever (zero, zip, nil, nada!), yet they see it fit to dictate how I treat my patients by establishing all sorts of bullshit rules to impede what I do. One such glaring example was when they came down with this firm no diversion policy, yet won't allow me to use the hallways to put, see and treat patients in because "It's against JCAHO." So when the ED is filled to the gills with no empty beds, patients being boarded because there is no room upstairs, the waiting room/lobby is filled with triaged patients to be seen, ambulances keep calling in, surrounding Podunc hospitals on the phone requesting transfers, etc…what the hell is a frustrated ER doc to do? Pull a magic wand out of his ass? On top of that, hospital administrators have a very uncanny way of pissing off the nursing staff to make them quit. Every month, more and more experienced nurses leave to go elsewhere, and I'm left to deal with incompetent and inexperienced traveller nurses. Some of them are great, but the majority of them are horrible. Then there's the contentious issue of utilization reviews and patient satisfaction survey scores to piss me off even more. I've blogged about this ad nauseum already.

I had to get away. The ER had made me become an angry and suspicious doctor that I didn't like. I hated myself for seeing every patient as a potential lawsuit and hated myself even more for the cynicism and bitterness that now grappled me after over 20-something years of medicine. When you start referring to patients as trolls and squirrels, it's time to call it quits. I had to get away. I had to free my conscience and get back to the humanity of medicine. So, I opened my own free clinic using the available spaces provided by a local church. I see patients 3 days/wk. M, T, W 10a-1p, break for lunch, then 2p-5p. That's it. Very limitted funding from the local churches in the community. Quite busy though. The only folks helping are the local churches and a few local businesses, radio and TV stations. I couldn't get the local hospitals to donate anything. Nor could I get any local docs to volunteer their talents either. I did get a few nurses to volunteer, though. I suppose the hospitals see me as a competitor and business threat, which made little sense to me because while I was working in their ED's these patients weren't paying them a dime anyway. But, hey, I know the game, the county hospitals do get some fundings for providing indigent care. However, here's my point, there are plenty of poor and homeless folks out there to go around and if I can do my part to keep them from coming to the ED's for non-emergent problems, shouldn't that be the goal? This month, I'm running real low on disposable lac trays, 4x4's, iodoform packings, 1% Lidocaine, 11 blade scalpels, betadine, and sutures. Heck, I'm running low on everything and have already spent a hefty hunk of my own money to get this clinic up and running. I spend the majority of my clinic days I&D'ing CA-MRSA abscesses, suturing lacs, refilling meds (antihypertensive and oral hypoglycemics for the most part), and stomping out sorethroats, coughs, UTI's and STD's. Lord knows that homeless folks gets freaky, too! There are no diagnostic studies performed, I just treat them and street them. Thank Jesus for $4 meds at Walmart (matched by Target, CVS and the other local pharmacies). The drug reps help, too. I love it when they bring free lunch. I'm under no pressure to prescribe any of the meds that they peddled, of course, since my patients cannot afford them anyhow. As to the liability aspect of it all, I'm not sure and try to keep as detailed records of each encounter as I can. I'm just hoping that the Good Samaritan laws apply and have been wingin' it day by day. All patients must sign a liability waiver to be seen. I may have to cut down to 2 days a week because of lack of fundings. I moonlighted in a Podunc ER the other day after a friend begged me to help out. The stock market is tanking, I may have to go back working for real pay.


Q2. Tell us how you are going to spend Valentine's Day.

A.2 Having hot steamy sex with my wife, like always, of course.

Q.3 One of the presidential candidates has asked you for some advice on how to improve the nation's health care system. What do you tell them?

A.3 The health care crisis facing our country is akin to a festering butt pus in dire need of incision and drainage. Like butt pus, it's well covered up so no one else can see, but it sure hell is a huge pain in the ass! My long rant on the subject can be seen here.

To summarize, we have a real national crisis at hand and it seems that none of our politicians know how or even care to solve. When over 47 million Americans do not have health insurance, we have a big problem. When a person in America has to make a decision between food on the table or pills in a bottle to take for his/her medical problems, it is a national disgrace. When a man have to resort to committing a petty crime to land him in jail just so he can get the medical care that he couldn't otherwise afford, it is disturbing. When hospitals pass on the costs of healthcare to the public by marking everything up by 1000%, we all have to pay painfully. When doctors, who all took the Hippocratic Oath, are too fearful of litigation to take care of patients, order more unnecessary tests (shotgun CYA medicine), spread the liability by consulting other doctors and specialists to get everyone under the umbrella, or worse yet, abandon clinical privilege at a hospital so he wouldn't have to take care of unattached, nonpaying patients...the situation sucks all around. When hospital and HMO administrators without any clinical experience or medical background can dictate what tests and studies physicians can or cannot order, the ship is being run by idiots and is doom to sink. We're headed toward disaster, there's no doubt about it. This isn't all new. Everyone knows that this health care crisis exist but our nation choose to turn a blind eye. It is analogous to knowing that the levees in New Orleans cannot withold a hurricane for decades but we choose to ignore it all the same.

So how do we go about solving our health care crisis? Well, let's go back to the butt pus analogy. Taking care of butt pus ain't as easy as you think, but it ain't impossible. A clinician must first be able to see the bigger picture and look beyond the patient's ass. For instance, is this patient immunocompromised, is he a diabetic, etc…? Otherwise, just cuttin' and draining the abscess won't address the underlying disease. How did this butt pus come about? Is it an infected pilonidal cyst? MRSA? And before cutting on this butt pus, one must ask, is this a peri-anal or peri-rectal abscess? Is there a fistula? You get the point, there's more to butt pus than just the ass, or meets the eye. The problem with our politicians is that they cannot look beyond the ass and thus are oblivious to solving the problem.

From the patient's perspective, health care should be affordable, easily accessible, and without compromise to quality. From the provider's point of view, liability is the biggest issue, as well as autonomy, reimbursement and quality of family life. The buzzword that we often hear regarding health care reforms from our politicians lately is UNIVERSAL HEALTH CARE. Yes, indeed universal health care is a noble endeavor that we all should strive for in this country. But our politicians are approaching it all wrong, sliding into the direction of socializing health care. There is a HUGE difference between universal health care and socialized health care, but too many people mistake them for one and the same. They are not! It has been shown time and time again throughout history that whenever the government has absolute control, all things go to hell quickly in a handbasket. Our government cannot even keep its promise to provide health care to our veterans, what makes you think that Obama or Hillary can provide health care for every American in this country? With that said, however, we can have universal health care without socializing it. In fact, you might argue that we already have universal health care right now. The Federal EMTALA law (Emergency Medical Treatment and Active Labor Act) requires that every patient who shows up to a hospital ER must receive a medical screening and stabilization if that hospital participates in Medicare. Without Medicare funding, a hospital is certain to go belly up bankrupt and thus EMTALA is pretty much inclusive of all hospitals in the USA. Private clinics, however, are not bound by EMTALA to do the same. So in a way, we already have, sort of, universal health care here. The word is long out. If you have no health insurance and can't pay for health care, go to the nearest ER. You don't have to pay up front and we are too scare of law suits not to take care of you. You can make up phoney information about yourself, fake who you are, give 'em aliases, fake phone numbers and addresses, phoney social security numbers and you'll never have to see that hospital bill. Heck, all the homeless folks show up every night looking for a warm bed and free meal anyhow, in addition to free health care, of course. Two hots and a cot, as we call it. Now there's a novel idea! If you have a real medical problem that needs true emergent care, like an acute appendicitis or a hot gallbladder that needs to be operated on or something...pretend you're a homeless drunk, mess yourself up a little bit, wear dirty old clothes, not shave or shower, sprinkle a little beer on yourself for the smell...and if you want to really get into the role...piss in your pants for the stale urine effect...show up to the ER of a hospital they'll have to take care of you. You'll never see the hospital bill, guarantee it!!! The beauty is they will never come after you, not for collections, not even with a 20 ft pole, not ever! So there, you see, we already have universal health care in this country. Albeit twisted and somewhat sordid, but free/charity healthcare nonetheless. EMTALA is a well-intentioned law meant to prevent patient dumping and abandonment. Too many people, however, take advantage of it and abuse the system. In honesty though, we're not all heartless, money-grubbing bastards. We're here to help everyone who truly needs our expertise.

Oops, I got a little distracted. We can achieve universal health care coverage for everyone in this country without socializing it through government mandates. And we don't have to do it either by forcing everyone to buy health insurance policies that they can't afford. And we don't have to require all employers to provide health insurance coverage for their workers either, because small businesses would go belly up. How can we achieve such a gargantuan tasks? Too good to be true? Not really. Our health care crisis is multi-faceted and complex, and addressing only one aspect of it alone will not solve the problem. Putting a band-aid on a butt pus doesn't make it go away! Over the years, many have blamed the increasing costs of health care on the enormous jackpot awards of frivrolous lawsuits brought forth by greedy trial lawyers, like John Edwards. Many states have tried to solve that problem by capping non-punitive damages on malpractice suits, but guess what, the plaintiff attorneys just worked harder, bringing up more lawsuits in order to make up for loss revenues they once enjoyed. Did health care cost go down? Not really. Did it make health care more accessible? Nope. More Americans are uninsured than ever and ER census across the country continue to rise in reflection to those numbers. Are doctors still practicing defensive medicine and ordering unecessary tests? You betcha, even in Texas and Florida. So do groundless lawsuits drive up the cost of health care? It may have contributed some but isn't the only factor that has made things spiral out of control. Mitt Romney, to his credit, tried to solve the problem by a different approach while he was the governor of Massachusetts. His plan, mandating health insurance coverage across the board for every citizens, has proven to be too expensive, even for the rich state of Massachusetts to stomach. Government mandates have never worked, and never will. I can't imagine poor Mississippi or Louisiana being able to do the same when the wealthy folks of Massachusetts have failed so miserably. The benevolent aspirations of Mitt Romney were there, but the execution, was all wrong, and it wasn't just the mandates alone. Though the plan addressed the accessibility of health care, it failed to address the other problems. For true health care reform to work, every aspect of the problem needs to be addressed:

Patient's perspective:

Accessibility

Affordability

Preservation of quality

Provider's perspective:

Liability

Autonomy

Reimbursement

Let's break it all down.

A) Accesibility. Health care has to be easily accessible to all. For over 47 million Americans without insurance (and that number is projected to reach 50 million by the end of the decade), it ain't so accessible. In many cities, aside for the safety net of the ER, there is little to nowhere else for these folks to turn to. But it need not be that way. We already have the infrastructures at the local and state levels to increase health care access. I say expand our local Health Department system. Give the health departments a more clinical role rather than just being there to provide routine vaccinations and monitoring of infectious diseases. Doing so would, in essence, establish a national health care system to where people who cannot afford insurance or a private clinic can go to for routine primary care. This would serve the poorest and most impoverished segments of our society, in addition to providing care for those lazy asses who choose not to pay for themselves, the so called leeches. How do we fund this expansion? The states are already funded through medicaid. Right now, the states are allowed considerable flexibility on how to execute the program that costs over $300 Billions/yr. Anyone who has ever done a shift in the ER's knows full well how rampant Medicaid fraud and abuses are. Let's eliminate some of that flexibility and force the states to beef up their local health departments to a more clinical/primary care role. Give sovereign immunity to health care providers who are willing to take a pay cut to work in our health departments (more on liability issues later). You want free care? You can't eat your cake and have it too. Eliminate Medicaid and establish a national health care system through expansion of the health departments. Let the states run them, if they don't want to relinquish control. But Eliminate medicaid! The reimbursement for medicaid, as it exists, is paltry anyhow. Most private clinics refuse to accept medicaid anyway. They shun them like butt pus.

While we're at it, get rid of the federally funded State Children's Health Insurance Program (SCHIP), too. Here's the truth to the notion of providing umbrella health insurance coverage to every child in America, it's wasteful and fattens the wallets of the insurance carriers and HMO's more than it benefits us tax payers. While it's a noble endeavor, it's not cost effective. At first blush, it would seem to be a grandly benovelent idea to require health insurance across the board for all children. You can hear the outcries, can't ya? "But, but, but...it's for our babies! We are the wealthiest nation in the world...and we can't provide healthcare for our children?..." Problem is, SCHIP is a gargantuanly expensive endeavour that does not provide the biggest bang for the bucks and makes no economical sense. Fact is, the overwhelming majority of kids do not get severely sick and have no need for expansive health insurance coverage. Sure they'll get the routine common colds, snotty nose, cough, sore throat and the sniffles. But for the most part, the majority of kids are healthy and are not afflicted with serious illnesses. Therefore, mandating health insurance coverage across the board for every kid in America is wasteful and serves the health insurance industry more than it does the kids. As a physician, I would love nothing more than seeing a well insured kid for a routine viral snot nose and sniffle in my ER. Quick 5 minute exam...Easy Chaching! But as a responsible taxpayer I see it as nothing but wasteful drain on our collective wallets. Day after day on duty I see hoards of medicaid covered kids rushed to my ER, sometimes even by ambulance, for routine snot noses and sorethroats. Sadly less than 10% of all the kids I see in my ER have a true medical emergency. Medicaid abuse is sickeningly rampant. Fiscal discipline and responsibility is called for here and "it's for the kids" can no longer cut it as an excuse.

Instead, for kids and healthy young adults, a catastrophic insurance policy makes more sense and is more cost effective, because these policies are much cheaper and are applicable in instances of unexpected calamity such as injuries after a motor vehicle accident, sudden illnesses requiring extensive/prolonged healthcare (meninigitis, appendicitis, new onset diabetes, broken bones ect...).

Abolish Medicaid and SCHIP! Use that $300+ Billions to establish a national health care system through expansion of the existing health departments. To get the manpower for the national health care system, give student loans breaks to physicians, PA's, ARNP's, RN's, LPN's, etc…who are willing to work for the health departments. Recruit students through scholarship offers to work in the health departments once they're done. 4 yrs of med school for 4 yrs of indentured servitude in the national health care system is a very fair deal, much like the military's GI Bill.

B) Affordability. Unless your portfolio rivals that of Bill Gates, Warren Buffet and the likes, for most Americans, myself included, we are all just one medical disaster away from bankruptcy, insured or not. Imagine a serious car accident, or heaven forbids, a diagnosis of some malignant cancer. If you're uninsured and play by the rule, you're screwed. If you are insured and think that your HMO will be there for you, you're naïve. ~$5,000 per day in the ICU ain't no chump change! The spiraling costs of health care just boggles the mind. By 2012, health care expenditures are expected to be about 17-20% of the GDP. A routine visit for an ankle sprain with a simple ankle series xrays used to cost $40 bucks when I first started medical school, now it costs $240 bucks! That's just the charges for the xrays alone, not for the visit, splints, crutches, nor is radiologist's charges for reading the films included.

There is a 1000% mark up for every thing as soon as you step through the door of the hospital. That's right ONE THOUSAND PERCENT mark up, not including physician fees, just hospital charges alone. One could argue that the $6 Tylenol pill is also paying for the heating and air conditioning, lights, utilities, house keeping, grounds maintenance, etc… But c'mon 1000%? Ain't that a little too obscene?

We've already established that socializing health care through gov't mandates does not work. It never has, but creating a national health care system as discussed above is absolutely necessary and would certainly increase primary care access for the extremely impoverished segments of our society who could not otherwise afford it. And for children and young healthy adults, a catastrophic insurance plan makes more economical sense as such policies are much cheaper. But what about the rest of us who plays by the rules and see government handouts as un-American and an insult to the very foundation of our democracy, self-reliance and individualism? How can we make health insurance more affordable for people who wants to take care of themselves and not rely on the gub'mint?

One of the main problem of our health care system is that there is no true competition. By that, I mean that there is an absolute lack of capitalism in health care. The spirit of capitalism is what made this country great, yet it is completely absent and devoid in the health care industry. From DRG fixed pricing through ICD codings established by Medicare, to the limitting and confining of insurance purchases within certain regions and state lines, capitalism does not exist in health care at all! And as a direct result, prices soar out of control to no end. To fix this problem we need to inject capitalism into health care and let the basic principles of supply and demand in economics take care of itself. Laissez-faire and let the market forces work! Let all of the hospitals and clinics compete. Let them set their own prices to drive down market costs. If at hospital A, I can get a hip replacement cheaper than at hospital B, transfer me to hospital A…If at the neighborhood clinic a routine visit is cheaper than at uptown clinic….you get the point. In the same vein, let all of the insurance companies compete across state lines. Allow small business, citizens of cities, towns, municipalities, etc…to band together for purchasing power to leverage for a cheaper price with insurance companies, much like the deals that large corporations can cut with these insurance companies.

The answer to our health care crisis is not to socialize it but to inject capitalism into it. Free enterprise! Let the market work!

C) Preservation of Quality. It is without question that we have the most technologically advance health care system that is the envy of the word. As it should be, because Americans demand no less. Any discussion in the overhauling of health care must include the preservation of quality that we currently have. Our health care providers must pass stringent criterias including appropriate trainings and board certifications. That cannot change as public confidence, not to mention safety, in our profession is of utmost importance.

D) Liability, Autonomy, Reimbursements, and Quality of family life (The physician side of the story). I would like to lump all of this into one discussion from a physician perspective, as these issues are all dynamically related and intertwined. As a physician who has been frivolously sued numerous times, I can personally attest that each case was equally gut wrenching and ripped me to the core. It was one of the major factor that weighed heavily and contributed to my decision to leave Emergency Medicine. Yes, every single one of those cases were completely meritless but they still haunted my psyche all the same. I hated to practice defensive CYA medicine. I hated myself for seeing every patient encounter as a potential lawsuit. Do groundless junk lawsuits drive up the cost of health care? Not entirely as recent studies dispute such argument that frivolous claims are the largest contributor to our health care problem. But one thing is clear, these junk suits certainly do contribute to the pie of discontentment making all physicians miserable. On top of that liability insurance costs are insanely astronomical. In my group of physicians covering an ED of 78,000 patients/yr. census, it costs us $1.2Million/yr in liability coverage. And that's cheap compared to other groups of comparable census in other states. Patients and their family bring suit, for the most part, due to bad outcomes. However, recent studies have shown that nearly 80% of all claims did not involve errors and did not receive compensation. So why the hell are the rest of us paying so much for liability insurance to the point that it cripples our business?

Escalating matters in our current health care environment is that more and more Americans are uninsured and the numbers are expected to continue to rise. And where do they go for their health care? They show up to the ER's across the country, of course, bogging down the system causing a serious overcrowding. Why do they not show up to the local clinics for routine nonemergent stuff? Well, that's because the clinics will first do a wallet biopsy as soon as patients show up at their reception desks. Thus, uninsured patients show up in hoards to the ERs because we don't and cannot make them pay first to be seen. That's the problem, EMTALA IS AN UNFUNDED MANDATE! I talk about the ER mainly because it is my field of expertise. But more importantly, I bring up this issue because unattached ER coverage is the single greatest cause of malcontent among the hospital staff of all specialties and subspecialties. As the growing numbers of uninsured patients continue to rise, compounded by the flood of illegal aliens, the safety net of the ER is the only place that these patients can turn to. At the hospital where I had been, our census doubled over a short period of 3 years. However, our ER reimbursement rate dropped to 27%. That means only 3 out of every 10 bills we send out get paid. About 3 out of every 10 patients we see actually pay us! Can you imagine any other business being able to survive on such piss poor returns? Just how do we survive and maintain our practice? The hospital has to kick in a subsidy, of course. But it's no where near enough for us to hire adequate staffing to be able to efficiently handle the patient load. The hospital in turn gets funding from the federal and state and local levels. What's more, the current nation wide nursing shortage bottlenecks our situation to a grinding halt on many nights. Not only are there not enough ER nurses, there aren't enough floor and ICU nurses as well. The facility actually has plenty of beds, just not enough nurses upstairs to take care of patients so they get boarded in the ER until one becomes available. Meanwhile, patients keep on showing up with no rooms to put them into. We triage and care for the sickest ones first, of course, and do the best we can. An average of 4-5 hours waiting time for nonemergent cases such as sorethroats, runny noses, toothaches etc..is not uncommon at all....which all equate to crappy Press-Ganey patient satisfaction scores and lower incentive driven reimbursements and bonuses for grunts like me. Damn vicious cycle and ploy isn't it.

The problem with uninsured patients is just not the financial aspect alone. Uninsured patients usually do not have a primary care physician. Because of such, many of them have not had any routine maintenance or preventive health care and have neglected themselves for years. They tend to be noncompliant with medical management when they do show up. It's pretty hard to be compliant, though, when you can't afford things such as medicaltions. Thus, it is of no surprise that the uninsured patient will usually have more complex medical problems and more comorbidities. From the consultants' side of the story, the longstanding rule is that for a physician to have practicing privilege at a hospital, he/she must agree to take unattached inpatient and ER calls. Now if you are a specialist or surgeon, why would you want to take call at a busy county hospital that requires you to see more patients, who are sicker, who don't pay, have more medical problems that are more complex with higher comorbidity and thus, higher liability? Yes, these are precisely the patient demographics that sue most often. Taking call at a hospital means that you'll have to work longer hours, see your family less, take care of more patients, with higher acuity, more complex comorbidities, who are likely to sue you more...and finally the kicker...not get paid for it. Furthermore, having to care for these unattached, nonpaying patients disrupts the physicians' private practice and detracts time away from their own paying clinic patients. As a result of this, outpatient surgical centers are popping up everywhere across the country. These centers allows a surgeon/specialist to maintain his/her clinic and paying customer base while not having to take on unattached ER and hospital calls. Likewise for this reason, many internists, family practicioners, and pediatricians have given up their hospital privilege and just maintain a clinic. I can't say that I blame them. Many factors play into why physicians abandon hospital privileges, but bottom line, higher census, lower reimbursement, higher liability are all major factors. And quality of life kinda sucks when you're spending more time at the hospital than with your own family.

To answer for fewer doctors wanting to take unattached calls, many hospitals have started IMS (inpatient medicine service) programs and are paying physicians to work as Hospitalists. Once the hospitals started paying the internists to take unattached calls, they opened a can of worms, as all of the surgeons and all the subspecialists soon started demanding compensation for taking unattached calls as well. With low reimbursement, limitted fundings, and all the specialties wanting a piece of the small pie, hospital administrators are faced with tough decisions as they cannot afford to pay everyone.

Such are the realities of modern medicine. So how can we fix this mess? What incentives can we offer to health care providers, physicians, esp. the subspecialists, to retain them at the hospitals and take care of patients? It is my personal faith in the altruism of my colleagues that I say I doubt there are that many physicians so cold-hearted to the point of refusing emergent care of a patient based on inability to pay. I personally believe the ones who do are very few and far in between. Admittedly however, this broken health care system does grind us all down and has undeniably made cynics out of us all, unfortunately. But I refuse to believe that those of us in medicine, entrusted to care for our fellow man, someone's father, mother, brothers, sisters, sons & daughters… have abandoned humanity altogether. The root cause for such discontent in the medical community regarding unattached calls is the fact that EMTALA IS AN UNFUNDED MANDATE. But as I said earlier, I don't think that any physician would deny emergent care to a patient based on inability to pay. What's frustating about EMTALA, though, is that it's a one way street that does not provide the physician any liability protection after being forced by federal laws to care for a patient with whom he/she does not have any established relationship with. Not getting pay for it is just adding salt into the wound. And the final thrust of the knife is the disruption of the physician's office practice by taking away the time the physician could have spent with his/her paying private patients. It's a triple whammy that leaves no incentive for the doctor to take call at a hospital at all. There will always be indigent patients, that's a given. But let's level the playing field. If physicians are forced to emergently care for patients with whom they have no prior established relationship with, then let's make it a little fairer by allowing sovereign immunity for EMTALA care. Let the physician practice medicine the way that it ought to be without the fear of litigation. Let the physician use his/her clinical skills and intuition instead of ordering unecessary tests out of fear of a lawsuit. That certainly would help cut the costs health care. Or at least establish a medical court to where physicians will be judged by a jury of their true peers rather than by an easily persuaded sympathetic jury. Let's face it, expert witnesses are a dime a dozen and both sides can pay a so claimed "expert" to say whatever each wants. I'm too familiar with this game after being embroiled in numerous groundless, frivolous lawsuits. Sovereign immunity for EMTALA care would be ideal, but let's be truthful, there are plenty of incompetent quacks out there who should have never been given a license to practice in the first place. Let's restore justice and establish a medical court system. You have patent courts, why can't you have medical courts? Surely you cannot expect Joe/Jane Average to be a fully knowledgeable and informed peer of a physician who spent well over 12+ years of higher education and training to hone his/her craft? It's only fair that we establish a medical court wherein a physician may be judged by an impartial and qualified jury comprised of not only respected physicians in the specialty pertinent to the case but also patient advocates who actually have a clinical background. If you think that physicians would be reluctant to punish another physician then you haven't obviously been to any hospital Morbidity and Mortality Conferences, esp. the ones held by the Dept. of Surgery. Those folks are brutal to each other.

Lastly, the lack of reimbursement for EMTALA care must be offset for the time spent. As has been displayed by the State of Massachusetts, mandating health insurance coverage for every citizen is unfeasible as it is too costly. But for physicians willing to take on unattached calls, not getting paid for the work and on top of that, a double whammy to the books from time detracted away from paying clinic patients hurt. This is essentially charity work so for fairness sakes, allow physicians to deduct non-reimbursed EMTALA care from their taxes. If you donate money or items to charity, you can deduct it from your taxes. This is no different. If you want us to provide charity/free care to the public, at least allow us to deduct a percentage of it off our taxes so it wouldn't cripple the operation of our clinics because when we're spending time to take care of uninsured patients, it is time taken away from our paying patients.

There you have it, those are my suggestions for overhauling our health care system. Make it accessible, esp. to those who can't afford it, by eliminating the inefficient and wasteful Medicaid and SCHIP programs to establish a national health care system through the expansion of the existing health department system. Make it more affordable by injecting capitalism into health care to allow hospitals, clinics and insurance companies to compete among each other. Ensure quality and patient safety. And lastly for health care providers, establish a medical court and level the playing field for EMTALA care.

Thank you Charity Doc for being Dr. February.