Pay as you go?

A recent article in The Wall Street Journal discussed its policy of requiring upfront payment from uninsured patients or those with limited health insurance policies. The article uses a case of a woman with newly diagnosed acute myeloid leukemia to review the hospital’s policies. M.D. Anderson Cancer Center is certainly not the only institution to have such policies on reimbursement for services rendered. Reading the article, I am struck at how this story highlights the fractures in our broken health care system. It speaks directly to the changes in our society more than to a change in medicine. Health care has traditionally been provided by employers and the government through employer-based benefits programs and Medicare/Medicaid. There are growing numbers of citizens slipping through these cracks as employers ratchet back their health plans.

Many Americans believe health care is an unalienable right when the reality is that our system is much more of a privilege. Access to quality medical care is largely limited to those who can pay for it. As a physician who practices in a public institution, I can tell you story after story of my patients who struggle with the burden of expensive cancer care.

I actually do not have a problem with the hospitals that insist on upfront payment from the uninsured and underinsured. I do, however, have a sense of great injustice that they charge these individuals more than they charge an insurance company. I cannot see the justification for a CBC costing dramatically different amounts depending on who is paying the bills. M.D Anderson explains they charge more to the uninsured because of higher risk. Well, that argument is implausible if they pay for everything upfront — right? This is the part of their policy which feels punitive — rather than just fiscal responsibility. It seems to me in poor taste to add insult to injury by forcing the unfortunate to both pay up front and pay more than the insured.