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with Rod Moser, PA, PhD

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Monday, June 25, 2012

Generosity vs. Entitlement

By Rod Moser, PA, PhD

Outstretched Hand

An interesting case: A mother of a twelve-year old diabetic child, an established patient, comes to the office because the child has ear pain. The mother is miffed because she was seen the day before at the emergency room, which diagnosed the child’s ailment as swimmer’s ear, and the child has not improved. She is demanding to be seen again at no charge in our office because the “ER Doc was an idiot,” in her opinion. She does not have insurance and claims that she has no money.

The child refuses to have her ear examined because it was painful to even touch it, not uncommon with swimmer’s ear. The parent and child state that her blood sugar levels were controlled, an essential question with a diabetic who has an active infection. Since the child will not permit an appropriate examination, the doctor decides to change her eardrops to a stronger, more effective one. The mother demands (not requests) samples. After a thorough search of the office, no free samples of this medication are found, so she is given a written prescription. Although our office does not provide free care when someone is dissatisfied with Emergency Room care provided by a different institution and a different doctor, her visit is “down-coded” (a considerably less expensive billing code) nonetheless and she is offered a 20% discount if she pays at the time of the visit. She chooses not to pay at all.

When she arrives at the pharmacy, she is upset at the price of the new eardrops, complaining that she had paid for a prescription the day before that did not work. She wants the pharmacy to give the new prescription for free. They do not.

The next day, she makes her own arrangements to see an ENT specialist who vacuums the debris from her child’s ears, confirms the diagnosis of swimmer’s ear, provides her with free samples, and only charges her $75 (a very low fee for specialty care).

She goes home and files a formal complaint against the ER doctor and the medical provider in our office. She is demanding that she not be charged for any of the visits, stating that our primary care office visit charge was higher than the ENT’s office (our charge would have been considerably less than $75 if she had paid at the time of the down-coded visit) and that her daughter’s ear was not vacuumed at the time of the visit. Because a complaint was filed, each person involved in the care of this child must take the time to write a written statement and make a determination whether her complaints are valid/justified.

Some issues to consider:

1.     Why would this child, with diabetes, NOT have insurance when she is qualified for Medicaid?

2.     Are medical offices morally obligated, because of a hostile patient encounter and lack of insurances and financial resources to provide any care for free?

3.     Are medical offices required to provide pharmaceutical samples to patients who do not have money?

4.     Primary care offices do not typically have a vacuum device, used routinely by ENTs, to clean out debris in the ear canal. Although other methods can be used, the child refused to have her ear examined and alternative methods are medically contraindicated.

5.     Are medical offices required to price-match, like some retail stores?

6.     Is the reversal of charges justified?

If a customer shows up at a grocery store, has a cart full of food, and then wants to be billed for the purchases rather than pay at the time, would the grocery store agree? If the customer has no financial resources, should the store provide this food free? If this person is qualified for a food assistance program, but did not take the effort to file the proper papers, should the store provide this food for free? If this same customer complains that the store prices are higher than other retail outlets, should the price be reduced? Because a customer is dissatisfied, should food purchases be free?

Most humans are inherently compassionate. They give money to panhandlers holding signs at freeway exits, even though they know this money may be used for drugs or alcohol. Medical professionals are no different, since many clinicians provide unsolicited financial assistance, quietly in the background, if we know a person is in need. Unlike the days in private practice where medical providers could set their own rules and charges, most clinicians work as employees now. The checker at the grocery store would have been fired had those groceries been provided for free. Medical providers are often chastised for giving away someone else’s money, too.

Over my four decades of medical practice, I suspect that I have given away thousands and thousands of dollars worth of free or highly discounted care. My heart makes me “down-code” a visit even though I know I am really giving away someone else’s money or supplies. I hoard pharmaceutical samples in my desks so that I can help someone in need (not the real intent of samples). I “forget” to indicate certain in-office procedures since I know they are expensive. I just do them for free. I suspect that I am not alone in this hidden social system. Other medical providers are doing the same. If a person is dissatisfied with my care, for any reason, I will not usually charge for a subsequent visit, but I would be reticent to reverse charges for professional services provided in good faith.

Medical providers have always been considered servants of humanity. We cannot refuse care because a patient has no money or insurance, but a grocery store can refuse to allow someone free groceries even though people are hungry.

Perhaps generosity fuels entitlement. The more that you give away free or provide highly discounted services, the more that may be expected next time, and the time after.

I would be interested in your comments about this case.

Photo: iStockphoto

Posted by: Rod Moser, PA, PhD at 6:28 am

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