Gentle Readers:

One could misconstrue The Czar’s posting of the magnificent Operative BG’s transmission as him running his own version of PRISM on your other Gormogons, but the reality is that BG’s communication, like many receive is an open letter to our collective brilliance. Usually one of us takes some initiative to answer letters in our sphere of influence, but sometimes things get hectic. Indeed, Dr. J. spent the weekend in the Florida Panhandle as Lil Resident and her dance troupe were laying the proverbial smackdown at Nationals, winning three titles (Age&Skill Category in Small Group, Large Group, and Line) and the Judges Choice award for best number (aka the Whole Enchilada Trophy™) for their line, so BG’s missive festered like a boil in our collective inboxes until The Czar decided to give Dr. J. a little hint to get off his duff via public shaming, rather than by the less effective but more showy tauntaun head in his bed.

Point made loud and clear Mr. The Czar!

Now, Good Operative BG, to answer your question:

The obvious answer is that between our Hippocratic Oath and the EMTALA law, emergent care is to be provided regardless of ability to pay. Even if it weren’t the law of the land, a doctor’s desire to heal the infirm is such that we would, by and large, still provide that care.

The real question is how does this emergent and necessary care get paid for. The easiest answer is that the institution providing the care doesn’t get paid and writes it off, paying for it out of their margin (aka profit in for-profit land).

When medicine and healthcare was a booming business, before the dark-times, before the Empire, the overage in private practice clinics and hospitals was such that it was seen as the cost of doing business. You always had that patient who paid in chickens or apple pie because that’s what they could do, and because your other patients were bringing in enough money it afforded you the opportunity to help the needy.

Given that third parties are paying physicians and the amount for physician reimbursement has gone down both from Medicare/Medicaid and private insurance, and with the aging population, that payor mix has become less favorable, private practice physicans are going out of business and being bought up by hospital owned multispecialty groups.

These multispecialty groups have reduced costs by less per physician overhead and cost sharing across specialties. A rheumatologist can be full time, not needing to supplement their income with internal medicine visits because the cardiologists’ revenues are helping prop them up.

As a consequence do dwindling reimbursement and the cost of doing business in the new environment, the immediate and necessary care will be delivered and come out of the shrinking margin.

Lets add Obamacare into the equation.

Obamacare is basically a shell game with federal reimbursement. The idea is that subsidized insurance will increased the pool of insured patients and thus there will be less ‘no pay patients.’ What this means is that you will make less money from medicare patients, and probably less money per insured patient, BUT you will be getting sufficiently more insurance patients compared to no pay patients that many hospitals should come out ahead. Unfortunately the folks who came up with this plan also front-loaded the bill with 4 years more money going into the treasury than coming out to get it under $1T that they can’t be trusted with anything involving mathematics.

So, if you’re an illegal alien, you’re ‘no pay’ and we will take care of you at no charge. We might send you a bill, and if you send us $10 a month to pay it we’ll take it (hey, that happens). If all of this amnesty stuff happens and you are ineligible for the dole, more of the same, unless you end up getting insurance because your income is now being tracked making you participate in Obamacare. If you get a job where your employer provides insurance as a consequence of becoming legal, good on ya. If the bill passes in a way that you are eligible for the dole, well, then it’s medicaid for you.

Dr. J. hopes that that answers your question. Thanks for writing in!

As a follow up to Little Red 1’s earlier email, apparently Princeton University has created a golden parachute for its senior faculty in response to the demographic crisis in the academy where there are so many healthy productive senior faculty members that it is choking off the pipeline of junior faculty members that have the opportunity to grow into tenured senior faculty. This may not appear to be a crisis to many, but the backlog will have a ripple effect such that when they depart, their successors will likely not be ready to have the baton passed. Think about the effect that Elizabeth II’s reign has had on Prince Charles and you get the idea. Its a real problem and tough to reconcile given that 60, 65 and 70 are not what they once were. But this is added proof that we need to shift the age of medicare and social security for life expectancy.

Dr. J.