THE EFFICIENT OPHTHALMOLOGIST

My two cent$: The impact of entitlement

Contrary to what you might think, we can do something about rewarding the “unentitled.”

By Steven M. Silverstein MD, FACS

This being the final column of the year, I am writing about a sensitive topic that affects each of us personally and professionally. Be aware that I am submitting this column one month prior to the November election for three reasons: First, like many of you, I am OCD. Second, my editor said I had to. But lastly, the broad space filled by issues resulting from entitlement should ideally be nonpartisan as much as they should not be about race, religious affiliation or culture; rather, entitlement should be solely needs-based. And yet, our politicians have made this about partisanship, so here goes …

Despite this bizarre political season, I resist the opportunity to discuss the ever-shifting paradigm of our medical landscape and the CMS-created alphabet soup-pot, to instead focus on the prudent, ethical uses and distribution of resources. Understand that, due to a deep sense of community responsibility, I have been a Medicaid provider for more than 25 years, and I fully subscribe to the notion that any strong society, culture or structured organization must in substantial part be defined by its philanthropy and recognition that there will always be those in need. In fact, history shows us that a society without this understanding seals its fate. Yet, for thousands of years, history has also demonstrated that every society that has not carefully regulated and balanced its entitlements has also failed. The bottom line: fewer and fewer providers can keep up with the ever-growing populace of those expecting more and more handouts.

To be clear, this is not what LBJ and the other bipartisan authors of Medicare and Medicaid envisioned. As an unprecedented number of billions of dollars ear-marked for entitlement programs are allocated, terms such as “work ethic” and “pride” are replaced with “inalienable right” and “expected and owed.”

STATISTICS

During George H.W. Bush’s administration, Congress responded to economic uncertainty and unemployment severity by passing three consecutive pieces of legislation to help those who lost their jobs. Ultimately, a worker could collect up to 20 weeks of unemployment benefits, depending upon, among other things, how bad unemployment was in an individual state. (Benefits are allotted by the state via business taxes, with federal support.) The Clinton administration extended those benefits if the person lived in a state in which unemployment was 9%.¹

In figures released in April by the Tax Policy Center, the top 1% of households, with average incomes of about $2 million, pay 43% of the federal taxes.²

The frequency of a social security disability review is contingent upon whether improvement is expected; possible; or not expected.³

CLOSE TO HOME

In our offices, we are asked to provide disability ratings for workman’s compensation injuries. Clearly, most of these unfortunate patients are deserving of these benefits and time to heal. Yet, how often are we asked to allow the patient to remain off work longer than necessary or to receive benefits for issues unrelated to a work injury? How often do our own employees call in sick or take unearned time off for “sick time” even after they have used up their allotted time?

For many years, I wrote off 90% of the unpaid “patient portion” of a patient’s bill while my billing staff accused me of having “too big a heart.” But, as regulations increase and entitlement criteria have become lower, compounded by health-care strategies that shift policies previously labeled catastrophic coverage into commonplace deductibles of $5,000 to $10,000, the number of patients refusing to pay what they owe has sky-rocketed. Sadly, so too has the percentage of people I must send to collections. My heart has indeed hardened.

When should government agencies tighten eligibility criteria so that people who can work but choose not to are denied entitlement benefits? The time for tighter regulations came long ago, yet the criteria for such benefits have only become more lax. The most sophisticated and enlightened societies must not feel guilty about expecting those who are capable to have skin in their own game, suffer the consequences of not being seen until their overdue bill is reconciled, or fired from the practice.

SO WHAT CAN WE DO?

Despite these realities, I love the practice of medicine and the physician-patient relationship. My youngest daughter is a first-year medical student, and I could not be more proud. I deliberately keep myself “blinded” to the patient’s method or ability to pay — everyone gets my best. But to combat these issues, consider the following:

1. Deny inappropriate benefits or time off for workman’s compensation claims.

2. Strongly urge patients to avoid insurance plans with ridiculously high deductibles, and encourage them to be responsible about paying their bill, if even only $10 per month when times are difficult for them.

3. Do not encourage the use of inappropriate resources such as an emergency room visit for non-emergent issues.

I hope when the time comes, you vote with your conscience in local, state and national elections for candidates who will allow us to take the best care of our patients and advocate for an appropriately healthy economy. OM

REFERENCES

Steven M. Silverstein, MD, FACS, is a cornea-trained comprehensive ophthalmologist in practice at Silverstein Eye Centers in Kansas City, Mo. He invites comments. His e-mail is ssilverstein@silversteineyecenters.com.