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Dear Editor,
Thank you for your fine publication. It is refreshing. In volume 6, No. 1,
under Thema , Douglas Wilson wrote that Christians should "hasten the destruction" of
the godless state systems by withdrawing our participation in government schools,
rest homes, food stamp programs, etc. I agree, but wonder how far you think
it should go?
Do you have any thoughts on Christian physicians receiving money (either directly or indirectly) by caring for Medicare and Medicaid patients? I am increasingly troubled by participation of Christian physicians in those programs. We no doubt help perpetuate these unbiblical programs by seeing those patients and accepting the government dole in exchange.
I realize that we are to help the sick. I realize that Joseph worked for Pharaoh under a State system, with God's blessings. And when State employees (soldiers and tax collectors) asked John the Baptist what they should do (after hearing and believing John's message), he told them to continue in their jobs, but to do so honestly. Any suggestions?
Frank Chin, MD
Camden, TN
Douglas Wilson replies: In response, let us refer you to the following excerpted
essay by Paul Glanville, MD. We present it not as a final word on a complex
problem, but rather as an invigorating first step. We are not necessarily in
agreement with everything Dr. Glanville says, but we do think he is on to something.
In the old small towns, "doc" knew everyone, and saw them all around town. He knew when they were having a rough time financially, when the cow had dried up or died, and he knew their character. If he heard they were ill and didn't have money for his services and were "too proud" to ask for help, he probably found some way to incidentally stop by and offer help. He probably would accept some kind of trade for services and could walk away feeling truly compensated, if not monetarily, knowing that giving to the poor is lending to God (Prov. 19:17).
I had a pretty good practice going from 1978 to 1988. Steady buildup to a comfortable level and all appearances of slow growth continuing, especially as I succumbed to joining some of the HMOs (Health Maintenance Organizations) and PPOs (Preferred Provider Organizations) in the Phoenix area. My personal gross income was about $72,000. I had a business consultant, a new computer system to handle all the HMO and PPO paperwork, a secretary and one nurse. With some more influx of patients I would probably need more staff, but would be making more money, etc. I wasn't overworked, putting in only about 35 hours a week including hospital and paper work, and only covered one weekend in five, switching call with four other private GP/FPs in a congenial manner.
Two years ago, I dropped my malpractice insurance. That could be a whole topic by itself, and I must say that it may not have been well thought through. But it was a "necessity" since I could not afford the premium. I had toyed with the thought for 15 years, always succumbing to the norm and disgusted with my gutlessness. I am sure that most doctors have entertained the thought many times. "Forced into" this situation, I believe by God, I finally said that I wasn't going to pay "protection money" to the mafia any longer, and I went bare.
Dropping the malpractice insurance meant that I had to drop out of all the HMO and PPO programs. I hated these programs and this was a relief, at least in the beginning. But then, I found out just how much of my income was from these programs. I lost about 70% of my gross business income overnight! You may say that I should have known this with the fancy computer system and all that. Well, I did have a good idea of what was going to happen. I just was hoping that it wouldn't. The loss of income from HMO and PPO patients (the Phoenix area is heavy in this area -- about 80% of all patients with any insurance are in these programs. This only leaves me with a pool of 20% spread all over the city and with their doctors already chosen) began severely squeezing me in the latter half of 1988.
Then on January 1, 1989, I said goodbye to my secretary and nurse, and began running my office with no staff people. My main phone number is answered by an answering machine that tells callers to come directly to the office during regular office hours and they will be seen without any appointments, then it gives the patients a phone number to call for urgent problems, then it gives the office hours and address, and finally gives them a phone number for non - urgent messages.
I began giving the patient's charts to each patient. They take the charts home, and are told to bring them in when they come to see me. Oh, what a ruckus this has raised in some of the medical community! I love it, and the patients love it! It works great! Patients almost never forget their chart, they enjoy reading it, they remember much better what I said was wrong, what I intended to do, what lab tests were for and the results, what I found on the exam, etc. If they need to see a specialist, I probably will write a little more of a summary note for his benefit, but may not. If the specialist needs a copy of any of the charts, his secretary can get that. Do you have any idea of how much your office spends in actual dollars for a copy machine and supplies?
My waiting room became a social center. Patients interact constantly, keeping up what occasionally sounds like a party. It is not unusual to say goodbye to a patient only to have them sit down to have a conversation with someone they know. Or to invite the next patient in and have them say, "Why don't you take him/her next. They seem sicker and I'm not in a hurry."
What about charges? I have a set of standard fees that I believe are fair for all insurance patients. They are lower than most of my colleagues' in two ways. First, the fee for each service is, in general, somewhat lower. But, in my experience, many of my colleagues are practicing the "bait and switch" game so often played by butchers. Patients are told what the usual charges are, but almost all visits end up being charged as a longer visit. Most HMO and PPO and Medicare patients never realize that they were charged for a longer visit, or in many cases for a procedure that was never done or was claimed to be longer or more extensive than what was actually done since they pay only a "co-pay" or the doctor accepts assignment for Medicare. The patient never even sees the bill, and they, in general don't care, saying something like this; "Well, the government/insurance is paying for it. It doesn't cost me anything." What ignorance!
For patients without insurance, my fees are discounted across the board, even if the patient makes quite a bit of money. Those fees are $25 for a first time visit, and $20 for regular visits after that. Recheck visits for ear infections, pneumonia, bronchitis, and so on, are usually $15 or $10, sometimes $5. I have found that there is something very healthy about my presenting the bill to the patient, seeing their reaction, responding to that reaction, reaching any compromise needed, and collecting the payment myself. I believe that this will lead to a much more honest system of charges and an important interchange in which doctors will find out something about their patients' financial status. Patients should not be coerced into borrowing money for medical care. So, if a patient indicates dismay at the charges, I find some way to inquire what they can afford. If I feel so led, I then decrease the charges to that amount. I feel there should be a minimum of $5, so that patients retain responsibi lity.
Well, what kind of trouble have I had? (1) Some patients couldn't handle this system and have left for another doctor. I am sure there are many of these of which I am not even aware. (2) Some patients have been disgusted at the answering machine and want to talk to a person in the office for several reasons. Many want to get a free phone consultation from me. For me to presume to be able to tell people over the phone whether or not they need to come in is a very dangerous game to play, not even considering the waste of time and the frustration involved. I do return every call I get. (3) Some pharmacists early in the implementation would call and call and never leave a message, thinking that someone would eventually answer the phone. They and the patient needing some refill would get upset. What I have been learning to do is to give the patient enough medication until they should be better or until they are supposed to see me for a recheck visit. (4) Conflict with the State Board of Medical Exa miners (BOMEX). This was exciting! I had no idea that I might elicit any problems with BOMEX. About two months after implementing the system I received a letter from BOMEX stating that they thought that I was in violation of the Medical Practice Act of Arizona.
I had a private interview with an investigator -- a semi-retired internist. We talked for about an hour. At the end of that time, he said that he really liked what I was doing, and he was going to recommend that the Board drop the investigation. I walked out and told God that I would prefer to not go back. I am an original gutless wonder, and have a really hard time with confrontation, being so easily intimidated it makes me ashamed.
About four months later I figured I was home free when I got a letter in the mail, summoning me to an open hearing with the entire board and their lawyers. They reiterated that they felt I was in violation of the Medical Practice Act in "improper medical record keeping and other unusual medical practices."
The Board interviewed me for about 45 minutes, asking me why I was doing these things. I had a good time answering their questions, and I am sure they were consternated to say the least. No one seemed antagonistic. They couldn't understand what I was doing, but they didn't seem angry. A vote was taken. Seven to drop charges, three to not, one abstain and a couple absent. With that we were ushered out of the room. I was in mild shock to say the least. My license had apparently been on the chopping block. Not to God, though.
In October, 1990 I had moved the office to my house. I love it! The benefits are many, the problems are few. My overhead is truly down to less than $10,000 per year (previously was about $14,000 per month when I had a secretary, nurse, and computer, etc.) -- probably less than $5,000. I seem to have lost very few patients and my patients like it. The income is still somewhat of a problem, but I think I know the reasons for that. But, the Lord is providing and providing abundantly.
I do schedule some patients for my house for female exams and complete physicals, but about 70 to 80% of my patients are now seen in their homes. And I have been seeing patients as far away as 25 miles!
In summary, I feel like a country doctor in the city. I know my patients again, and they know me. I remember their names much better than ever. Most of them seem like personal friends, and we have a good time during the office visits. I am ready to have to tighten the belt if needed, and plan to learn to live below my income, something I always said I was going to do, felt I should do, but never really did. I learned many other valuable lessons from that time that I plan to share more and more as they become clearer.
Used by permission from Paul Glanville, MD. Printed in full in the Journal of Biblical Ethics in Medicine, summer, 1990, vol 4, number 3, titled "Forward to Basics in Family Medicine". Their mailing address is P.O. Box 13231, Florence, S.C. 29504-3231.
