Just Like Someone Without Mental Illness Only More So_ A Memoir - Mark Vonnegut [55]
I have had heartbreakingly accomplished patients kill themselves or become heroin addicts. It’s not enough to play an instrument perfectly or to get a full scholarship.
As soon as a new hurdle is set on the path to getting into medical school (organic chemistry, higher and higher GPAs, higher and higher board scores, extracurriculars, community service, moving personal stories, et cetera), the ability to clear that hurdle spreads through the applicant pool like the ability to resist penicillin spreads through a petri dish. Everybody is throwing a lot of pasta up against the wall hoping that it will stick. Any essay that works will be reworked and reworked and reworked some more.
Some applicants were accused of trophy collecting. It wasn’t enough to be a concert pianist, work in a first-rate research lab, or save a small South American village. It had to come from the heart.
After watching so many candidates I liked go up in flames I suggested to the dean that each committee member be allowed to advance one applicant a year to the final pool without the usual debate. He thought it was a good idea and would bring it up to the committee.
Is a doctor really that special a thing to be, or are we making too big a deal of this? It’s like we’re all scrambling to get to a place a little higher up on some slippery pyramid because we don’t know how high the water will be when the tide comes back in.
Sometimes my father would call me out of the blue. “Is this the doctor on call?”
“Yes, it is, Dad.”
“Sorry about your profession. I wouldn’t be a doctor for anything. That’s got to be the worst job in the world.”
When I became a pediatrician, a short visit cost ten dollars, a checkup was twenty. People paid cash. Our overhead was 27 percent. Our books were kept on a yellow pad. We were free to determine the content of the visit, which mostly consisted of asking patients or parents what we could do for them and taking it from there. When medical insurance came into pediatrics, it seemed like a good deal because we would suddenly be paid twice as much for visits and procedures and our patients wouldn’t be paying anything out of pocket, since it would all come out of the insurance that was taken out of their paychecks. We also realized we had no choice, since no matter how much they loved us, most families would take their kids where the care was covered by their insurance. We also had to get computers and hire people to track whether or not we got paid and do a bunch of other stuff. There goes the overhead.
In the fine print it became illegal for us to charge the uninsured or anyone else less than we charged our insured patients and it also stipulated that the insurer would pay us at a discounted rate for our charges. The net effect was that my professional services went from something my patients could easily afford to something that, without insurance, they couldn’t.
When I ask pharmaceutical salespeople what a new drug costs, they hasten to reassure me that it’s covered by insurance and will only cost the patient a ten- or twenty-dollar co-pay. Co-pays are the tip of the iceberg. Without insurance all these new, absurdly expensive medications could not exist. With insurance it becomes suddenly worthwhile for pharmaceutical companies to spend millions and billions pushing less-than-necessary medications to providers and patients. These costs push up the cost of other medications and insurance and care in general. If you believe that the dollars made by the pharmaceutical industry are plowed back into research that leads to better and better medications, you probably believe in the tooth fairy as well.
A dispassionate look at all the many innovations of the insurance industry, from HMOs and managed care to co-pays and prior authorizations, would show that each innovation was a way for insurers to make money at the expense of the public good. If these innovations were studied like a new drug or medical device, they would be taken