Thursday, August 20, 2009

Why pro bono labor from doctors won't help

David Lazarus of the Los Angeles Times wins the Knucklehead Idea of the Week Award. In his recent op-ed he posited that doctors should be required to provide one week of free labor for people without insurance in order to "help fix the healthcare system."

Thousands of people lined up last week for free medical treatment at the Forum in Inglewood. The arena floor resembled a vast healthcare assembly line as hundreds of patients at a time were seen by dozens of doctors, dentists and optometrists.

But many others had to be turned away because of a shortage of medical professionals willing to volunteer their time and expertise.

Stan Brock, founder of Remote Area Medical, the nonprofit group that organized the Forum mega-clinic, was clearly frustrated by being unable to match the overwhelming demand for healthcare with a sufficient supply of caregivers.

If local doctors aren't willing to donate their time -- a big enough problem on its own -- why can't physicians from other states come here to do
pro bono work?

See, this is the problem we have with "fixing the healthcare system": everyone with a keyboard has an idea and throws it out there with the admonition that if we just do this or that, it might help. Pro bono work from random physicians certainly couldn't hurt, so why not do it? In fact,let's require it. I'll leave alone the whole disconnect of requiring charity work, and go over the counterpoints to Lazarus' plan from a systems standpoint.

1. Doctors already give steeply discounted service when they accept Medicaid. The reimbursement from this payer is so low that it is universally subsidized by an outside entity or other paying patients.

2. Working in free clinics is horrendous for professionals and patients alike. Shotgun doctor-patient relationships are inadequate to manage complex problems. Any labs, xrays or meds would not be covered and the patient would be left with recommendations that could not be followed.

3. Physicians are just one part of a large, intricate system. We rely on our trusted staff and other professionals in the community to help deliver the health care product. To force a doctor to work in a foreign setting without his/ her staff and referring colleagues would be counter-productive.

4. Health care delivery is best done with continuity. To go to a free clinic one week per year is ludicrous. The physician could not verify that proper follow-up has been rendered and that progress is being made in a treament protocol.

5. Free clinics could give the uninsured and underinsured a false sense of security that they will be provided quality care without payment, and thus disincentivize people to get necessary insurance coverage. It sends the wrong message.

6. As presented in the Lazarus' column, clinics would have difficulty verifying that these traveling doctors are qualified and safe.

Let's review a scenario. Dr. Jones, a surgeon from a suburban practice, goes to the inner city free clinic to see patients pro bono for his required week. On Monday he sees Mr. Pickins who has right upper quadrant abdominal pain, boating, jaundice and nausea. Dr. Jones suspects gall stones and orders lab tests and an ultrasound. Mr. Pickins has no insurance or family physician. Dr. Jones has no idea if Mr. Pickins has any money or insurance to pay for these tests or surgery if it is necessary; Dr. Jones does not know the office staff well enough to be confident that they will follow up with Mr. Pickins to make sure he doesn't have a pancreatic tumor. If the labs and ultrasound are actually done-- very unlikely-- and gallstones are diagnosed, then who will do the surgery? The surgeon on the list for next week?

The entire week is full of patients with suspected hernias, meningitis, chest pain and pressure sores. Dr. Jones has created doctor-patient relationships with dozens of people with no ability to ensure that proper follow-up has been carried out. This would be a disaster that corrupts the little semblance of "system" that each doctor struggles to create.

Lazarus tries another approach:

So let's try this instead: As a condition of licensing, a medical professional would be required to demonstrate that he or she treats at least a tenth of patients on a pro bono basis annually.

That is, for every 10 patients that a healthcare provider sees, one would receive the same level of care as all the others but at no cost.

Here are the problems with this scenario:

1. Nothing is free. The costs would merely be transferred to paying patients seen in the office.

2. Again, labs, xrays, surgery, medications and hospital care would still need to be covered. We work within an integrated system and doctors' labor is just one very small part of the cost.

3. Again, this sends the wrong message that patients don't really need to be responsible because every physician in the country will be required to have "free" appointment slots. Heck, patients could even shop around!

4. Who would do the means testing to ensure this free care is for truly indigent people?

5. In my experience, patients who are not required to pay are also at high risk for being noncompliant with appointments and care. They have very high rates of failing to keep appointments. This is costly and disruptive to a medical practice.

The problems with health care in the US are myriad, but the two universal issues are that 1) we lack a system approach, and 2) our costs are too high. David Lazarus' hare-brained scheme would exacerbate the first problem and do nothing to alleviate the second. It is typical of quick-fixes that try to avoid the heavy lifting of actually fixing the healthcare problem.

A much better idea would be to hook these uninsured and underinsured into an existing program that does means testing and provides comprehensive coverage. Half-measures are dangerous for everyone involved.

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