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If I was about money and efficiency, I absolutely would not take Medicare; it takes a huge amount of time and effort to get things that are standard approved, like scans and nausea meds. They do pay less than other insurance companies---sometimes by a lot. The truth is, if it were feasible, my costs---and those of the patient--- could go down by not taking any insurance, as I would have to pay less staff to wrangle care out of these insurance companies. I think it is feasible for primary care in certain geographic areas, and for luxury things like elective surgery, plastics primarily.

However, my diseases are so expensive that only the very rich could afford to pay out of pocket, given the scans, biopsies, and drugs; that's just the way it is, and so it isn't really an option to get rid of insurance companies for oncologic diseases.

I also think it's unethical to say, "only high rollers need apply; the rest of you, good luck!" I'm in this to try to make a difference in the world, and it's not fair to say, "Sorry you didn't maximize your oppotunities earlier in life; you are going to pay with your life now, because I won't take you." I take people on Medicare, Medicaid, and those with no insurance. To large degree, the ones who DO have insurance subsidize those who do not, by which I mean that I come out enough ahead on those that do reimburse that I can give a lot of care for which I will never see a dime. It is something I have to limit; some of the drugs I use have a negative margin, i.e. I may have to pay $500 to acquire drug X, yet Medicaid may only pay $425 to reimburse me, so I have already lost money, and that doesn't even account for the 200-day delay in reimbursement that Medicaid has (I have to be out the cost of the drug that long after I bill it), or the staff and inventory costs....
I could not afford to stay open if all I did was Medicare and Medicaid, or no insurance. I'd be way ahead financially if I stuck to good insurance only, but you have to be able to know you have done the right thing. I worry that long-term, docs will put up with this less and less, and over time we will have an evolution to a VA-type system: slow, inefficient salaried docs with poor language skills. (Please don't flame me for this; of course there are lots of wonderful VA workers out there, but I've worked in lots of VAs and if you are honest, you know exactly what I am talking about.)

A greedy doc says, "no Medicare, no Medicaid, and no uninsured." A really greedy doc says, "For $2000 or 10000 admission fee yearly, plus cash for treatments, I will treat you few high rollers really nicely." These are generally affluent, relatively healthy patients. It's called concierge medicine, but really it's like licking all the frosting off the cake and leaving the rest if the spongy mess for those of us who are willing to help the less fortunate. They justify it by saying, "this way I can spend more time on patients rather than running them through." But that leaves a huge number of patients shifted to those of us who try to treat everyone, not just the well-heeled.

Selfishly, I should be against health care reform: it will probably make my bottom line worse as a doc, take a lot more time, and as one in a higher tax bracket, I'll pay for it on that end, too. But this is America, and people shouldn't have to hope they can quickly scrounge up coverage for their cancer before it gets them, or worry that they will lose their farm to pay for it. Even a drug-addicted prostitute, full of long-term bad choices, should not be eaten up with cervical cancer because of financial issues. I think basic health care (not plastics for vanity or similar things)should be a right; by the time lots of my patients find out they should have gotten coverage, it's too late, as they now have a prequalifying condition. Medical catastrophes account for a significant proportion of bankruptcy. It shouldn't happen in America.
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