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Health care's tough choices

Were I not a witness to this, I wouldn't have believed it: A young woman came into the office of a Tampa oral surgeon and nearly got booted out over a $15 bill. She had a seriously abscessed tooth _ a golf ball-sized swelling of infection on the side of her face. She was in pain and could hardly talk. I was there for the same problem. She looked as hurting and scared as I felt.

The woman was summoned into the receptionist's inner office and within minutes everyone in the waiting room was painfully privy to the fact she owed $15 on a 4-year-old bill. She tried to explain that she had moved several times. No matter: The receptionist was loud, combative, belittling and relentless in her mission to collect the debt. I wonder if the receptionist's exuberance was of her own volition or if her zeal had the tacit encouragement of her boss. A friend who had accompanied the woman pulled $15 from her wallet and gave it to the receptionist. "For God's sake, here's the money. Everyone can hear you."

You bet we all heard. We shifted uncomfortably in our seats and exchanged embarrassed glances. Another minute and we all would have pitched in. What if no one had come to the young woman's rescue? Would she have been refused care?

Most critics of President Clinton's health care plan say it will mean rationed care. I hate to be the bearer of bad news, but we already have rationed care. It's rationed according to who can afford it, by who has insurance and what kind, by the good will and morality of the doctors who treat us. Anyone who doubts the need for health care reform and universal coverage needed to be in that surgeon's waiting room.

We want to believe our doctors and dentists are caregivers and healers who put our welfare above making a buck. Many do. The practice of medicine, however, has changed since our parents were kids. Doctors are entrepreneurs who set up their practices as corporations. They charge interest if patients must make payments for medical care. They have business managers who tell patients how much money they need up front before care is rendered _ all under the pretense of insulating the physician from the distasteful task of refusing care to those who don't have enough money. And unless Americans remain fervent in their desire for better and more affordable access to health care, the rugged battle ahead will become impossible to win: The American Medical Association is the most well-heeled lobby in the United States. Physicians aren't shy about pressing their interests, and Americans are smart enough to know money talks in the halls of Congress.

A tooth abscess is no small thing, it's not something a person can weather with some aspirin and rest. Head infections are serious and, left to fester, they can travel from the tooth root into the bone, becoming far more serious osteomylitis, a bone infection. Then they require surgery to scrape the infection from the bone. If the infection eats away too much bone, they require bone grafts. The infection can threaten vital organs. They require long weeks of intravenous antibiotics.

My infection migrated into my jaw bone and I am on intravenous antibiotics. I am doing what I had never dreamed I'd be even remotely capable of: giving myself intravenous antibiotic infusions. I fill needle syringes, flush the catheter in my vein, set up the IV medication and spend 45 minutes doing this every night. I am blessed with insurance through my employer and am able to get coverage for most of this treatment. Without insurance, taxpayers would end up footing the bill.

Rare is the person who has never needed a doctor. Our physicians fix us up, make us well, stop it from hurting, answer our calls when we have emergencies. They allay our fears because beyond common sense and the commonplace, most people don't know a fauces from a foramen. Who doesn't want our physicians fairly compensated?

To those of us whose lives have been saved by a surgeon, we know they're well worth all the money in Fort Knox.

A financial crunch

Hundreds of people tell stories of care denied and lives lost, of lives and livelihoods devastated by catastrophic illness, of disease that could have been prevented, especially among children, the most vulnerable and powerless in our society. Some 35-million Americans have no health insurance, 2.5-million of them are in Florida. We heard their stories during national forums last March. And I am still struck by the notion that greed could be elevated to a level where a sick person was harangued over $15.

This isn't an isolated incident. A colleague needs surgery for a serious condition she has had for a couple of years. Her operation was canceled at the last minute. It is not elective surgery. Her surgeon, a highly regarded Tampa Bay-area practitioner, received a predetermination notice from our insurance company stating it would pay $5,000 of an $8,000 surgery fee. Dissatisfied, the surgeon's business manager said my colleague had to fork over $3,000 up front. They wouldn't work out a payment plan. She said she'll have to wait until she can put enough money aside. She already has gone so long with the problem, what's another six months to a year? The surgery involves removing tumors and unclogging fallopian tubes. But what if, in the course of trying to pull the money together, the condition develops into an emergency?

The infection in my jaw bone started from an abscessed tooth. Treatment started with a root canal. The abscess was the last thing I needed. During the past year and a half I have traveled to specialists at Shands Hospital in Gainesville and in Virginia where I had several intricate micro-neurosurgeries to correct painful damage to the nerves in my jaw. Insurance doesn't cover everything. Travel is costly. I was not a newcomer to the endodontist's practice: His partner did a root canal four years ago and I paid my bill. I explained my financial crunch and asked if the endodontist would accept payment in parts. He told me they accepted credit cards. I told him I had far exceeded my credit limits because of the surgeries and other medical expenses. Then he said, "Can't you get it from your family?"

Professional courtesy

Anyone who has seen medical bills mount knows the humiliation of explaining money troubles, the frustration of losing some semblance of financial independence, the fear of going deeper in hock and the insecurity of seeing emergency funds whittled away. Like most working people in my position, we find ourselves facing the tough choices of paying the mortgage, keeping the lights on, or getting our tooth abscess treated. Part of the problem is that so many doctors and dentists have lost touch with the realities of what their patients go through. One reason: They themselves rarely pay a doctor bill.

It's called "professional courtesy," an old custom of giving free or cut-rate service to one another. It's been criticized recently in the New England Journal of Medicine as the debate over health care reform has intensified. Those opposed to the practice argue that physicians giving freebies to each other unfairly shields doctors from the high prices they expect their patients to pay.

The average salaries of physicians have soared during the past decade while the salaries of others have lagged. Most people are clueless about how much specialists make. A telephone survey done for the USA Foundation found that most people think radiologists earn about $100,000 a year _ and believe that is too much. Radiologists actually make an average of $250,000. The survey showed Americans grossly underestimated the paychecks of doctors, insurance company executives and hospital administrators.

The entrepreneurial spirit rules, sad to say, in one of our most precious assets: our health. America and South Africa share the distinction of being the only two developed nations where health care is not considered a right. Physicians are vehemently against price controls, saying the quality of medical care could be sacrificed. But when was the last time the AMA came up with any ideas? The AMA did release five "New Year's Resolutions" for 1994: Its ambitious and lofty goals for the public welfare included urging Americans to "Conduct a Home Safety Inspection" and "Learn CPR."

Usually, though, doctors and dentists devote themselves to more crucial and sophisticated aspects of medicine through continuing education at conferences, symposiums and seminars. A huge national surgery conference in Orlando last fall focused on topics such as "Advanced Techniques with Endosseous Implants" and "Sinus lift Surgery." No one, however, presented a paper on "How to provide dental care for the working poor." The last item I read about the American Dental Association was its decision last month to spend more PAC money _ some $2-million _ on grass-roots lobbying efforts as opposed to national campaigns. So what gives?

Dr. Daniel Lew, president of the American Association of Oral and Maxillofacial Surgeons (AAOMS), said its members "are urged to do their share." Apparently, the urging packs all the punch of a fly-swatter.

Ask Bea Dreir about recruiting doctors to treat the working poor. Dreir is the director of the Judeo-Christian Clinic in Tampa, which provides free and cut-rate medical care to those who can't otherwise obtain it. Dreir started out trying to recruit physicians and dentists "any way I could" to volunteer a little of their services. They weren't exactly lining up. Then she enlisted the help of the president of the Hillsborough County Medical Society, who wrote letters to its membership. It paid off: Enough doctors now volunteer so that each works only about one night a month. But it took that subtle arm-twisting.

Even so, with 1,200-plus members of the county's medical society, only about 100 doctors and dentists volunteer at the clinic. They get no pay and no recognition, but their medical care is cherished and has helped people who would otherwise suffer or end up in emergency rooms. Dreir said some mainstay physicians are so dedicated they have seen patients for free at their own offices.

Other physicians don't hide their disdain. They say, "Oh, those people," when Dreir sought help for patients at the clinic.

"They think the government takes care of them, or that they need to help themselves," Dreir said. "Some doctors are just not motivated. There are those who will never come out here."

If doctors' professional organizations won't tackle the problem and the majority of physicians find it too burdensome to devote one night a month to caring for the poor, why does the medical establishment get its back up over government intervention when the problem reaches a crisis?

Although Americans disagree over various approaches to health care reform, Clinton deserves credit for having the guts to take on powerful, entrenched interests: doctors and insurance companies. He deserves credit for making the issue the center of national debate when the last two administrations barely broached the subject.

The problem, Lew said, is that medical professional organizations wear two hats: One is the advocate for the public's health; the other is the advocate for its members. They don't reconcile the conflict very well. And these days, it seems, the second hat gets the most use.

I asked Lew what AAOMS has done toward promoting its support of universal access? Has it put its money where its mouth is? Been involved in crafting the Clinton plan? Proposed its own? Engaged in discussions? Made its support known?

"When the time is right," was the answer.

I think AAOMS is a day late and $15 short.

Gina Thomas is the assignment editor at WTOG-Ch. 44 in St. Petersburg.

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