A Second Look

Fewer physicians may be accepting
Medicare and Medi-Cal patients, but altruism
and volunteerism are far from dead.

HUNDREDS OF PHYSICIANS and other health care workers appeared on the steps of the Capitol in April to tell the public, the Governor and the Legislature what it means to patients when:

• California ranks below Mississippi, Tennessee, and New Mexico in total health care spending per Medi-Cal patient.
  
  
• Medi-Cal managed care capitation rates are the lowest in the nation.
  
  
• Inflation-adjusted Medi-Cal rates have declined by 54 percent since 1985.
  
  
• Low Medi-Cal payments reduce the dollar for dollar federal match, so Californians are subsidizing other states.
  
  
• The customary fee for a basic office visit is $66; the Medicare fee is $48.15 and Medi-Cal pays $18.18.
  
  
• The customary fee to repair and stitch a layered, complex wound is $230; the Medicare fee is $189.01 and Medi-Cal pays $14.95.
  
  

All this when the state is awash in billions of dollars of surplus revenue.

However, the CMA report that informed the demonstration, "Improving Access to Health Care for Medi-Cal Patients," also contained a 1994 survey showing that 31 percent of physicians did accept new Medi-Cal patients and 43 percent did accept new uninsured patients who could not pay full fee. That made us wonder about the other side of the access coin.

Locally it is especially hard to get dermatology, neurology and orthopedic consults for Medi-Cal eligible children, yet some specialists do see Medicare, Medi-Cal and underinsured or uninsured patients, and some physicians who do not routinely accept Medicare do see Medicare-eligible patients at reduced or no fee.

Several years ago, senior medical students and residents talked to me about physicians' ethical responsibilities for charitable service. They complained about their burdensome debt as they enter post-graduate training or practice and begin their families. They argued it was unreasonable and unfair to expect them to give their professional services away for little or no pay and that low payment they would receive from public and private health care managers was charity enough.

However, in their midst was a medical student whose family fled from Vietnam to a United Nations refugee camp in Cambodia where they received free, life-saving care from a physician. Her whole purpose in getting to medical school was to "give back" and she intended to provide pro bono medical services to those in need. Another medical student revealed that a free East Bay street clinic had gotten her off drugs and she intended to work in a community clinic right away and always. Debt repayment would stretch out; family would wait. A resident reported that working in a community-based clinic during his training had been so gratifying that he never wanted to give that up entirely. He intended to volunteer his services at the clinic where he had trained.

Maybe shamed by such stories, others began to talk of expecting to take emergency calls even though payment was unlikely, of expecting to take "hard" cases along with the easier, more profitable ones, of intending to practice in rural or inner city communities even though that meant less income.

That launched our present search to learn about medical "volunteerism," especially among "unavailable" specialists. We learned that a smaller percentage of physicians now accept Medicare and Medi-Cal patients than in 1994; but altruism and volunteerism are not dead, only buried under the debris of mountainous overhead and intrusive micro-management. (Our reports beginning on page 15 tell more of the story.)

Volunteerism may now be less motivated by altruism than by enlightened self-interest. Many in the "unavailable" specialties have embargoed their services to teach the public and private "tyrants" of medical-cost management a lesson, but instead they are punishing the patients. As with any embargo, we need to find ways to serve the tyrannized (patients) while depriving the tyrants of their power. Volunteerism may be the way.

Ed_Rudin@macnexus.org