American Medical News
October 1, 2001
Ethics Forum
Facing patients who don’t pay
Scenario: A patient recently forwarded the following notice he had received from his physician to the attention of the AMA’s ethics standards staff (some facts and names have been changed to protect the identity of the parties):
“Dear John:
“We recently received a returned check issued to us by you on Jan. 17, 2001. The amount of the check was for $40. We will be unable to refill any prescriptions or see you in follow-up until this check amount and the bank fee of $25 is paid in full, by cash. Payment must be made in full in 10 days or else we will be turning you in to the state attorney’s office for writing a check for insufficient funds. We will no longer accept anything but cash for our services to you as a patient.”
If the patient brought this letter to your attention, how would you advise him?
David A. Fleming, MD, Associate Professor of Medicine, Director of the Center for Health Ethics, Dept. of Health Management and Informatics, University of Missouri Columbia School of Medicine:
“Medicine is a profession, not a business — or is it? Although this letter seems unduly harsh and uncaring, the squeamish feeling we have when reading it stems from knowing that many of us have sent similar letters to patients who did not or would not pay their bills.”
“If health care were a normal commodity, bought and sold in a normal market, it would be a simple matter. If you don’t pay for the goods, you don’t get the goods. But the ethical challenge for physicians is in the fact that health care is more than a commodity that can be bought and sold like a loaf of bread.”
Comment: At best, unpaid medical bills result in patients losing access to their usual sources of care, whether terminated by the provider for non-payment or terminated by the patient because of shame over not having “honored their financial commitments.” Even worse, unpaid medical bills can result in financial ruin, and is now the second most common cause of personal bankruptcy. Although physicians and hospital administrators pride themselves on delivery of charity services, almost all of this charity is not in the form of gratuitous care offered to those in need, but rather it is in the form of bad debts adjusted off and retroactively labeled “charity care.”
We surely can devise better methods of assuring access to care for those that do not have adequate resources without subjecting them to humiliation and without unfairly and haphazardly shifting costs of that care to others. Establishing health care equity in a society with inequitable distribution of wealth is quite simple. Every other industrialized nation has figured out how to do it. Simply provide comprehensive health care coverage to everyone, and then fund that coverage in a fair and equitable manner. What are we waiting for?