(KEY OFF)(KEYWORD) WOMAN COMES TO SEE me for a pelvic examination. I am worried because her cervix looks red and ulcerated -- markedly abnormal. It might be infected, but it could be cancer. After explaining that, I prepare to do a pap smear.
"No!" she objects. "Please don't. Just treat for infection. If it goes away, fine. If not, I'll get it rechecked later, when I can." A free- lance writer, she lives hand-to- mouth. She has no insurance. "If you find out I have cancer," she says, "they'll never sell me insurance. And without it, I can't afford to get treatment." She leaves with an antibiotic prescription. I am depressed all day.
Money troubles -- the whole impossible tangle of medicine and money. There's the exorbitant cost of health insurance and the almost- prohibitive cost of medical care for some who need it, on the one hand. And on the other, there are the problems of insurers, doctors, hospitals and industries that finance health care for their employes. Everyone is unhappy. Everyone has legitimate concerns. And I'm unhappy and perplexed when I see the effects of these problems -- and some of our efforts to control them -- on peoples' lives:
After performing one of those sophisticated, expensive tests we can do now, I have to tell a man whose immune system looks abnormal (a condition sometimes associated with AIDS) that he should think carefully before leaving his boring government job to branch out on his own. His insurance is good and there's a possibility he might really need it in the future. Insurance for individuals costs so much that losing coverage has become a major consideration when we plan life changes.
But the cost of hospital treatment is only part of the problem. An asthmatic man comes in gasping for air. A taxi driver, he has not been able to work because the wheezing gets so bad when he attempts to drive. Medicaid pays the hospital bills. But he does not meet the District's strict disability parameters, so he has no income.
When he was released from the hospital a week ago, he'd been in reasonable shape. "What happened?" I ask. "I was out of my medicines, and I had no money," he confesses. "So I tried to make some money driving. But I lost my breath again -- and I had nothing to take for it."
This cycle of interrelated health and money problems seems to occur time and again. This month and next, I'm trying to write about medicine and money -- why everything costs so much, how the system is out of control, and why it is so frustratingly difficult to rein it in. Next month, I'm going to look at the money problems endemic to our institutions -- the hospitals, the way we teach our medical students, and the explosive growth of technology that can astonish -- both by what it can do and what it can cost. But this month comes the hard part -- money and people like me, doctors.
Caring for people like the asthmatic cab driver, I cannot help sharing their worries when the bills become overwhelming. We feel bad about the cost of needed tests, adjust our own fees and hope things get better for them. If there's insurance, we're relieved. They will not be devastated by the cost of an urgent operation or a long illness.
But I cannot help recognizing the insurance companies' problem as well. Dying patients accumulate $150,000 hospital bills.
Magnetic resonance scans (the most precise non-invasive way to see inside the body) at $700 a shot threaten to supplant CAT scans at $300. And people are prepared to spend absolutely anything -- especially if it's paid for by the insurance company -- to get the care they believe or have been led to believe they need. When costs soar, insurance companies get socked for the bills, and they increase rates the next year.
Businesses and industries get socked as a result. Much of what might be profit is paying for employes' health care instead. Local companies pay an average of $1,255 a year for each employe. And the federal government also gets socked. To slash costs, the Reagan administration proposes everything from the elderly paying more of what is now covered by Medicare, to eliminating medical students' low- cost loans. And after years of subsidizing the cost of training house staff in university teaching hospitals, the government wants out.
Somewhere, the system has to give. Either people who need care are going to have to pay more out- of-pocket, or they are not going to get the care they need, or medical care will have to get cheaper.
Why is it so expensive in the first place? We doctors and our earnings are an obvious target. Many believe we're getting rich from others' suffering. According to the American Medical Association, there are 519,000 doctors in the country. In 1983 they earned, on average, $106,000. Among us are more than a few whose earnings top $250,000 a year. They skew that curve.
If that much goes to a highly specialized surgeon whose technical expertise came after long, extremely hard years of training and whose work may keep him in the hospital 16 hours a day and in the operating room 10, I am not much bothered, personally. I could not tolerate that life myself, and wouldn't be any good at it. But I want that person practicing if I need delicate heart or brain surgery. If big bucks help keep him working, that's all right by me.
But I'm enraged -- as are most of my colleagues -- to hear about doctors who earn that much by gouging the public, charging twice what others do, ordering excessive tests or unnecessary procedures. There are those who will bill $40 or more for 5-minute visits and see 10 people an hour that way. One of the problems is that there is not much we can do to drum these people out of work -- unless patients file formal complaints with local regulatory agencies -- much as we'd like to. Review groups are looking at in-hospital visits to make sure days hospitalized are not excessive. Some insurance plans require that doctors be willing to submit their practice to review by other doctors. But this rarely happens. There is no routine mechanism to make it happen.
Most of us internists earn much less than those specialists who make six-figure incomes. I'm paid about $55,000 a year, depending on how much care I provide. Granted, I've chosen to work for George Washington University Hospital for a salary, rather than be in private practice. But in Washington, people at health maintenance organizations and in the early years of their practice don't earn much more. And the national average income for pediatricians is $61,500 and for family practice, $63,000, says the AMA.
What we earn comes after seven or more years of famine, and in the face of student-loan debts that for some top $100,000 before interest. During residency training we punish ourselves with backbreaking workloads that tax us physically and emotionally and often wreak havoc on our families. A woman who graduated with me from George Washington went into a surgery program in California, and was sorry at the onset that she wasn't married, because she thought the support would help. But by the end of the first year, five of the 11 people who en tered training with her were either separated or divorced.
But there's more to it than that. In medicine, I've discovered, the word compensation takes on a more primitive meaning. There are things this work takes out of you that nothing can replace. On some gut level, you get the feeling that you need -- indeed deserve -- compensation. And it's desperately hard to find compensation that seems adequate, that assuages some of the stress and the pain.
A friend used to hoard $5 a week from her minimal resident's salary to buy herself a cheap pair of earrings each week. They weren't beautiful or substantial, but they were something that had nothing to do with the hospital -- and they were a reward of sorts for the punishment of 100 or more hours of work each week in her demanding internal-medicine residency.
And the stress does not end when training does. Try balancing an angry 2-year-old who needs her mama's attention on your knee at 8 at night and keeping her subdued while you explain to the niece of a sweet gentleman who just died in the hospital what went wrong.
It doesn't surprise me to see people who have just finished training blow an entire week's salary on clothes. I did that, once. And when it didn't satisfy me, I tried buying toys for my daughter, Annie. But that isn't healthy, either.
My problems are not going to rate me much sympathy.
They are the concerns of a privileged member of a privileged society. I understand that. I'm practicing medicine because I want to, and some people think that should be compensation enough. They add a double-bind -- if I wanted big bucks, I could have been a neurosurgeon. They add that the very fact I chose internal medicine means I know everybody in health care gets so fat it doesn't matter what I choose to do. And no matter what, they add, we spend too much on doctors in this country. That's the bottom line.
If I add that we spend too much on lawyers and on plumbing bills, too, I'm being obnoxious. If I confess I honestly wouldn't mind having 11 percent of the GNP go to health care (which it does), if only that money were buying the kind of care I think all people should get -- and now certainly are not -- I'm naive. And if I admit I'd rather buy health than guns with my taxes, perhaps I'm seditious.
What's worse, I'm a supposedly intelligent physician in a national center of health care, and I cannot figure out a sane, compassionate way to reduce medical costs. Part of the problem is myopia on my part -- I'm inside the system. Part is that the system is simply out of control. Health care does not cost this much in other countries. Why does it here?
Some doctors go into medicine for money, and some charge outrageously. (If medical school applicants talk about money or job security during interviews at GW, we weed them out quickly; but most people are too smart to mention such things.) But doctors' salaries, no matter how hard you look at them, still come to only 15 percent of what we spend each year on health care.
A group of internists I know in Washington who opted to remain part-time have still not brought home a single dollar in salary in their third year of practice. It's not that they're not successful, and it's not that they don't charge standard fees. They have a busy, well-regarded practice. But the annual rent is $23,000, and renovations cost $55,000, which had to be borrowed. Their employes -- a receptionist, a bookkeeper and a part-time lab aide -- cost almost $40,000 a year. Malpractice insurance runs them $5,000 annually. And bad debt -- people who don't pay their bills -- runs 15 to 20 percent. Among them, they end up putting in 80 hours a week at work. "My spouse has been supporting me," says one. "I don't know how the others are managing."
In the District of Columbia, like other big cities, wages are high and office space near a downtown hospital, expensive. Add the cost of an information storage and retrieval system, laboratory and equipment needs and office maintenance, and the fees go up.
The billing system, which seems to have grown up without rhyme or reason, exacerbates the problem. "The trouble is," comments a young internist, "we're not really compensated for what we do best. Internists examine people and talk with them, and the insurers don't recognize much value in that. If I do a complete physical examination which takes an hour or more, I getabout $40 from Medicare. But if we do pulmonary function tests with a spirometer, which takes minutes, we get paid $50 a test."
The complaint my friend voices has been a focus of debate in medical circles for years. Why should a doctor get paid $100 to evaluate rectal bleeding with a flexible sigmoidoscopy that takes 30 minutes of his time -- and have the insurance company pay the entire amount -- then evaluate a hypertensive person and counsel about diet, exercise and medication for 30 minutes and get paid $35, none of which is reimbursible by insurance? These are both procedures that can be done in the doctor's office, by the doctor. And all the money goes to the practice's gross income.
And how did the sigmoidoscopy fee get set in the first space? Nine months ago, a private gastroenterologist in Washington was charging as little as $55 for a screening procedure, when the university clinic was charging $125. This month, that private doctor's fee is up to $100 while the university's clinic fee has dropped to $90. At Georgetown, where the procedure is done in-hospital, the charge is $165, plus a room fee. (Worse, shopping for a bargain is tricky. If an internist were to find something wrong that merits a biopsy, the patient usually gets sent to a specialist to have it done again, at least doubling the price.)
In the medical community, what gets charged, by and large, seems to depend upon what other people in the area are charging, and, of course, on what Blue Cross and Blue Shield are willing to pay.
In the past, they've paid too generously. But they're beginning to become innovative about cutting costs. Some of what they're doing makes great sense. They require second opinions about surgery, offer financial rewards to those who bring expensive billing discrepancies to their attention. And they are going into the health maintenance organization business in a big way.
But cost containment is much easier with young, essentially healthy people, than with those who who live much closer than most of us to the edge:
A fragile, elderly woman came to us with her blood pressure extremely high and her blood sugar out of control. She was terribly agitated. She'd just gotten notice that because she had signed a petition to get the hot water turned back on in her apartment (it had been off for months), she and others in her building were going to be evicted.
Our social worker contacted a lawyer who'd represented the woman in the past, and we increased her medications. A week later, she returned. Her pressure was even higher. And she was tearful. She and her elderly gentleman friend had been robbed by some young thugs who had taken the television and whatever else looked as if it might be worth a dollar. They'd had a gun, but fortunately didn't touch the old pair, who look so fragile you would expect them to be knocked over by a harsh word.
We increased the medicine again. The next week, the resident caring for her with me came in beaming. "You won't believe it -- you have to see her," he said. "She's dressed in her nicest clothes, she's smiling, and her pressure and sugar are great!"
"What happened?" I asked.
"She won the lottery!" We won, too, it turned out. Next time she came in, she baked us an apple and a sweet-potato pie.
Four visits in four weeks.
Health-care need created as much by the exigencies of life for the poor and the elderly as by anything strictly physical. And health-care costs that must be met somehow.
Traditionally, part of the cost of care for those who are sickest has always been paid by those who are well -- through our insurance systems, Medicare and Medicaid. Cuts in these programs that directly help the elderly and the sick poor, and insurance plans that cut costs substantially for the young and healthy, will ultimately factor out those who are sicker and poorer. What will happen to them if this continues?
Reexamination of our health-care system is certainly healthy, and changes are desperately needed. But it is not clear to me whether an ethical framework -- which to my mind demands that we help care for those who cannot help themselves -- or a federal regulatory system or a private marketplace will prevail. And since these options have very different implications, I think it behooves us to explore them carefully and conscientiously before we make up our minds.