In-Dentured servitude

Yeah, dumb pun: the article was sent to me by a dentist…

It’s a short post, so I grabbed it all (go read his, though, for the links to the source material, and to read a good blog by a Navy Dentist).

New Jersey Assembly Bill , A.B. 4175, introduced on 23 November 2009 will require physicians, dentists, and nurses to complete 30 hours of volunteer service in their respective fields as a condition for biennial registration.

Well…..Guess what New Jersey? This is the final straw. You just lost another provider. Happy? Whose going to treat all those folks with insurance now?

via Down in the Mouth: Involuntary Servitude.

So, this is one of those weird times where those potentially affected say ?wha?  Is there some pressing reason to command volunteerism in order to be licensed?

I’d be willing to bet you could find a few people in every medical profession who think they must never treat anyone for free, and barring some scheme like that proposed in NJ, they’d be legally right.  Morally, I don’t know.

This is one of the reasons EMTALA is widely derided in the emergency department world: the difference between generosity, giving your time and talent without expectation of reimbursement when it’s needed and you’re able , and State coercion, the taking of your time and talents whether you consent or not.

(“You can stop taking Medicare or quit your job” you say, and while the second is correct the first is not, as I’m hospital based and required to accept Medicare, and the strings attached).  Also, it’s quite a thing to be expected to quit ones’ job to avoid having my work literally taken from me by governmental fiat (thanks, Pete Stark).

I wonder what the NJ medical, nursing and dental societies thought of this?  I’d bet if they made a public statement it was at least mildly supportive (imagine saying “no”, and being pursued by some idiot with a camera and a mic yelling “don’t you care about the children?”).

For some reason if your job is thought of as one of compassion many people, governments included, expect you to be willing to do it for free.  I don’t get that.

(An aside for those of you with business outside medicine: you can write off bad / uncollectable debt; we can’t).  (No, I don’t know why, either).

Someday medicine is going to figure out how to explain that it’s not the bad guy, that we’re giving way more than we take.  And make it understandable to everyone.


Comments

  1. In-Dentured….Ha!…are you trying to make an impression? (another bad dental joke)

    Thanks for posting this. I appreciate it greatly!

    R/

    DocV

  2. This is also connected to part of the “logic” of some arguments about health care reform. No one wants to pay for those without insurance, they’re very happy with those in health care just working and not getting paid.

  3. A lawyer (of course) in the legislature proposed this for Oregon several years ago for MDs and DOs– to do 50 hours per year of state-approved “volunteer” work. I’m sure only work with “the homeless”(addicts and crazies) and “underserved communities”(illegals) would have qualified.

    The bill was defeated but bad ideas always seem to revive.

  4. “Someday medicine is going to figure out how to explain that it’s not the bad guy, that we’re giving way more than we take. And make it understandable to everyone.”

    Where can I bet the over on that?

  5. TheNewGuy says:

    Typical… these toads are so quick to demonstrate THEIR altruism with OTHER PEOPLES’ time and resources.

    Bottom line: none of these guys in the legislature will give a hoot until it’s their child who can’t get care… or until they’re at home with a toothache, unable to find a dentist, and desperately searching for a pair of pliers… anything to stop the pain.

    As for the typical snark from our resident PI attorney, I’ll ask Matt again, as I have so many times. How much of your work do you explicitly do for free, knowing up-front that you won’t get paid?

  6. Were you going to bet the under on physicians getting organized and decoupling themselves from the government? Why don’t you pick a time, and we’ll bet it between us. C’mon, if you think I’m just being snarky, put your money where your mouth is.

    You guys gave them the right to dictate your time and resources. You ask the government for everything, and then are surprised when it wants something back but by then you’re so tethered you can’t get free. FYI, their child will never not get care. There will always be physicians. Especially for the well connected.

    How much of my work? I don’t know on a percentage basis. I won my county’s pro bono atty of the year last year so I guess Legal Aid keeps track. They refer me most of the pro bono work.

  7. Atrocious and unbelievable…where is the requirement for the congressmen to do the same…or any other profession? Why do we suddenly have a target on our backs? (somewhat rhetorical question, Matt)

    Here’s an interesting question- would ER doctors be able to be signed off on their volunteer hours based on how much free care they provide? Here is the text of the bill:

    As used in this section, “volunteer medical services” means medical care provided without charge to low-income patients for health care services for which the patient is not covered by any public or private third party payer, in accordance with such standards, procedures, requirements and limitations as are established by the board.

    Sounds like a good chunk of business for the average inner city ER is given to those who “are not covered by any public or private third party payer.” If the physician fee is written off by the hospital as charity care then the physician providing it would have been volunteering their services, right?

    Now I’m guessing that the board could make restrictions that say that your hours need to be separate from your usual paid shift but who is to say that the board would let that slide and let any and all uncompensated care be considered “volunteer medical services” for the good of all involved

  8. TheNewGuy says:

    Are we talking about decoupling ourselves from the government now? Way to change the subject, counselor… but on that point, screw you, Matt. I had no part in the current deal-with-the-devil the medical system has with the government. None of us did… it was all before our time.

    We were actually talking about medicine finally getting across to people that we’re actually the good guys in this, and helping them out far more than they realize. Medicine mainly has a public relations problem… partly thanks to guys like you, Matt. And you make money on it.

    But let’s face it… there’s too much money to be made by demonizing my profession, so I don’t have much hope that our message will ever get through.

    And when when your pro-bono work is 50% of your billable hours, like the 50% of my volume that’s self-pay/Medicaid, you can lecture me on not doing enough.

  9. (An aside for those of you with business outside medicine: you can write off bad / uncollectable debt; we can’t). (No, I don’t know why, either).

    The answer is simple accounting. It has to do with the difference between cash accounting and accrual accounting. If you are using the cash system, you never included the “bad debt” in your income, therefore you can’t “write it off”.

  10. Parameddan says:

    I think I see both sides of the argument in regard to the comments, vaguely at least.

    My only question is: What if the money that is provided from the government (my-your taxes) is completely removed from the equation. All the way from undergraduate loans that support pre-medical students to medicare or medicaid and medical research funded by the NIH. Then I would say asking a physician to provide free service would be absurd in this hypothetical scenario.

    However, government funded programs are an inherent part of our medical system. Many, not all I’m sure, physicians have directly benefitted from the role of the US government in their education and their funding. A specific community service requirement more than likely isn’t the worse thing that could be asked.

  11. Dr. Kranky says:

    So since YOU too have benefited at some level from government (i.e. your tax dollars and mine) spending, like Student loans to Medicare/Medicaid funds that support YOU and your family and friends, can *I* determine how much and what kind of “community service” you should be compelled to do?

    Government funded programs like public schooling, the courts, police and fire are an inherent part of the overall system. Man , I”m sure, average citizens have befitted form the role of the US government in their education and funding. A specific community service requirement more than likely isn’t’ the worse thing that could be asked.

    Incidentally , Parameddan, what to YOU do for a living. How have YOU benefited from the public largesse? When will we see YOU lobbying the government to have all those like you compelled to “give back ” to the community?

  12. Dr. Kranky says:

    So I gather, Matt that you’re all for having the state pass a law to COMPEL you and your colleagues to do pro bono work?

  13. Bob Rakov says:

    If they are required to complete 30 hours of volunteer service as a precondition for licensing, then how can the service be deemed volunteer? It’s really more like a tax isn’t it?

  14. TheNewGuy says:

    Paramedden:

    Are you a paramedic? If you’re paid by the city/county, you might not care if you have to pick up indigent patients; you get paid either way. You’d sure care if your pay depended on actually getting reimbursed.

    In fact, with the growing pay gap between the public sector and private sector, I think it’s time for you guys to give something back. I think you need to spend X hours off-the-clock picking up bums, winos, welfare queens, and illegal immigrants.

    I’ll bet you went to a government subsidized school too. It’s time to pay your fair share, Comrade.

    See how this works yet?

  15. “Medicine mainly has a public relations problem… partly thanks to guys like you, Matt. And you make money on it.”

    I don’t make any money on your bad PR. I have nothing to do with your PR.

    “See how this works yet?”

    So where are the legislative proposals by physicians to decouple themselves from this system? I see physicians asking the government for MORE all the time, but I never see them asking for LESS. Yet you want to complain the government asks more from you.

    Do you see how that works yet?

  16. “And when when your pro-bono work is 50% of your billable hours, like the 50% of my volume that’s self-pay/Medicaid, you can lecture me on not doing enough.”

    You, like many physicians, apparently don’t know the definition of pro-bono or charity. That’s work you do where you don’t intend to get paid. If it’s self-pay, you have the right to collect, and you intend to collect when you do the service. If it’s Medicaid, while you may not make as much as you want, that’s not pro-bono or charity.

    I’m not lecturing you on not doing enough. I’m lecturing on constantly whining about the very forseeable results of choices you made. YOU made them. If you don’t like the results, then make a different choice. Either way, quit whining incessantly.

  17. TheNewGuy says:

    I don’t make any money on your bad PR. I have nothing to do with your PR.

    You’re too funny. You may not NOW… but you used to. You made money on making physicians look bad, but it’s all good, because you were acting as a fiduciary, right?

    If it’s self-pay, you have the right to collect, and you intend to collect when you do the service.

    BS. You can’t get blood out of stone, and all of us know it. In fact, we don’t even try… for instance when they’re obviously illegal and have no documentation or address, we pretty much know that’s the end of the line. We write off plenty of debt as “uncollectable.” As for Medicaid, that’s a pittance.

    The point is that we’re forced, by law, to see everyone and anyone… regardless of ability to pay. It’s forced indentured servitude, and there’s no “decoupling” to speak of, since it’s a completely unfunded mandate from the feds.

    That you don’t understand the difference between that and our mandatory enrollment in Medicare (that is, if we want to work at any hospital) is actually pretty funny. It gets worse every year, and most of it was a done deal before most of us even entered practice.

    How would you like a forced mandate of “pro-bono” work?

  18. “You may not NOW… but you used to. You made money on making physicians look bad, but it’s all good, because you were acting as a fiduciary, right?”

    This remains incorrect. I don’t make any money on making physicians look bad, never have. The one medical malpractice case against a physician I handled involved a physician who performed a tubal without the patient’s consent, then falsified the records so that no one would know. I personally did nothing to make them look bad. The physician did that on their own.

    “BS. You can’t get blood out of stone, and all of us know it.”

    All well and good, but it still ain’t charity if you don’t INTEND not to collect. You have no idea WHAT the financial circumstances are of those that come in, you’re judging solely on appearances. If you choose not to pursue collection, that’s a business decision you’re making. But there are a lot of agencies out there dedicated to squeezing blood out of those very turnips. Still, that’s not charity on your part.

    “The point is that we’re forced, by law, to see everyone and anyone… regardless of ability to pay. It’s forced indentured servitude, and there’s no “decoupling” to speak of, since it’s a completely unfunded mandate from the feds.”

    Nonsense. You’re not “forced”. You choose to in order to get the government money. You sign a contract whereby YOU get government money, and in exchange the government says in order to get our money, you have to take all comers. No one makes you sign that contract. And no one dupes you as to its terms.

    It’s not “mandatory” that you enroll in Medicare.

    You’re right that Medicare was enacted before most of you got in practice, but the government pay has worked pretty well for you guys for decades. For some reason you believed that the pay would always go up, which speaks more to your naivete than anything. So now it’s time to figure out a way to wean yourself from it. You’ve known this was coming for a few years – come up with anything?

    “How would you like a forced mandate of “pro-bono” work?”

    Depends. How much do you make annually as a result of this contract you sign that you consider “forced”? The average ED physician makes what, $180,000 on average? I’d consider it strongly for that.

    Although truthfully, your public defenders, which also take all comers, make significantly less. So there are people in my profession who are willing to take the tradeoff already.

  19. TheNewGuy says:

    You don’t read very well, do you Matt? Any ER physician who wants to be employed MUST accept Medicare… because the hospitals that employ us REQUIRE us to, unless it’s some unique institution like the Mayo (which doesn’t take Medicare).

    You’re also not making the distinction between Medicare/Caid reimbursement issues, and the EMTALA mandate.

    And once again, you attempt to deflect from the fact that none of us in current practice made the deal-with-the-devil that we currently have with Medicare. Last time I saw the stats, 40-45 cents of every health care dollar goes through federal hands… so unless physicians decide to strike en-masse (which would cause a lot of deaths, about which your ilk would endlessly castigate/litigate), the feds are driving the train.

    And before you whip out your standard “AMA-blah-blah-blah” boilerplate, the AMA doesn’t represent me.

    You should stick to what you know.

  20. So let me understand what you’re saying. You know that 40-45 years ago your predecessors wed you to Medicare/Medicaid. You knew this when you entered medical school, and you knew this when you chose a specialty.

    EMTALA itself is nearly 25 years old. When did you enter medical school?

    So if none of you made this deal, how are you trying to distance yourselves from it?

  21. 30 hours a year! Thats nothing. We end up doing 48 every call weekend.

  22. Ayn Rand spelled out this behavior long ago in Atlas Shrugged, a book that I believe all med students should read. I don’t believe in all of her precepts–as a physician, I do, for example, believe in altruism–but what she writes is largely a prediction for the near future for the United States. Medicine happens to be on the forefront of forcing producers to work for the good of others at the point of a gun, because (1) doctors are among the few true “producers” of anything of value left in the US, and (2) its easy to identify medical care as a “need” (therefore a “right” for citizens), thereby excusing the unconstitutional abridgement of the rights of the producers of such care. Its for the good of the people, you know. It won’t be long before the air traffic controllers have to give community service time, or firemen or garbage collectors.

    And for those physicians wanting to quit because of this type of law–well Ayn Rand illustrates in Atlas Shrugged that soon quitting your job will become illegal, too.

  23. This one is easy to comply with. Just have your office manager pull the chart of dead beats greater than 90 days past due and write off the hours as charity.

    At least you can deduct 22 cents per mile to get to work on the days you provide charity care

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