Cold Hard Cash
That will be cash please. You may be hearing this more often at your doctor’s office. MSNBC recently reported a trend in medical practices to accept only cash payment for healthcare, citing a number of advantages for a cash-only practice.1 Dealing on a cash-only basis cuts out all of the red tape associated with insurance payments, as an office may have to deal with more than 100 different companies. Overhead is dramatically decreased--fewer personnel are needed because the multiplicity of forms required for insurance filing would be rendered unnecessary. In many instances, entire personnel positions can be eliminated, thus making up for the loss of revenue from a cash-only practice. Doctors are freer, so the article claims, to do what they do best: take care of patients. But is this really a good idea? Let’s look at some of the issues involved.
A cash-only practice would have benefits for most healthcare practitioners. One could charge reasonable fees for services rendered instead of the inflated prices now used to create “wiggle room” in insurance contract negotiations. Fees could be tailored to individual the patient and circumstance. Accounting would be straightforward and up to date. There would be little or no concern for late submission of fees or documentation.
Cash-only practices are not a new idea. It was the way doctors did business for thousands of years until the twentieth century. But can we get twenty-first century healthcare to fit back into a cash box? Many of the subspecialties, technologies, and procedures available today would be difficult to access on a cash-only basis. Since it is the responsibility of the patient to pay for services rendered, and since health insurance is the preferred method for paying, the onus for filing the necessary paperwork for reimbursement should be on the patient, not the physician’s office. In such an arrangement, patients would be at a great disadvantage in dealing with health insurance companies, which typically reject a claim for even the smallest filing infraction.
One of the original purposes of health insurance was to provide people with a few resources to obtain basic healthcare. What has emerged is a cultural assumption that healthcare is a civil right—not just for basic care, but for all care. Medicaid now pays for many procedures and treatments, such as organ transplantation, that were once carefully rationed. Patients expect more from their healthcare than they did before insurance was paying the bills. This expectation would crash headlong into a cash-only practice where available services or care might be limited by the ability to pay. Only patients who had very little to treat or a large bankroll to spend could have the best that medicine has to offer.
Doctors may benefit from a cash-only practice, but would they use it to advance the goals of healthcare, or themselves? A founding principle of the medical profession is that doctors would treat patients regardless of their ability to pay. Before the days of insurance, doctors were only moderately compensated for their services, which generally placed them in the upper middle class of wealth. They were in fact honored and revered for the vital service they provided, without primary concern for compensation.
The twenty-first century doctor works differently. Medicine now operates on a business plan. Escalating costs for increasingly complex services have made medicine one of the biggest businesses in the United States. Doctors are now highly compensated, and no one that I know of is looking to decrease his or her salary. So, how would doctors deal with a cash-only practice now? Practices may be able to care for some charity cases, but most would simply exclude non-paying patients. Any clinic run on a cash-only business plan would have to focus first on the bottom line—cold hard cash.
Physicians with a Christian worldview already have enough problems with the business model of healthcare. It is increasing difficult to show Christ’s compassion and build personal relationships when minutes count as dollars. A cash-only practice may help slow down the busy pace of a physician, but it might also keep many patients from ever stepping through the front door. Perhaps there is some middle ground, such as a more flexible pricing structure, which we can seek. As Christians, we need to balance our personal witness of God’s love with the larger perspective of how the body of Christ can best minister to society as a whole.
So while, the idea of cash-only medicine is appealing, it just won’t work in the twenty-first century. Patients’ expectations of what they are entitled to would simply not fit back into a cash system. Physicians also have changed their expectations to those of the business model of practice. Whether physicians have a Christian worldview or not, there is little room for any of the altruistic nature of the medical profession to show forth. Until our physicians are willing to be medical professionals instead of business partners, and until patient expectations are more realistic, we should leave the cash box closed.