The silence of money in medicine

Money is a delicate topic, even for physicians.

This seems counterintuitive. Those who can easily discuss life-altering maladies and reset broken limbs with bare hands shouldn't have trouble with something as mundane as finances. A new rule should be, if you can talk sepsis and dilation, you can talk supply and demand.

Except in medicine, as National Public Radio found in its recent story on Lewiston, discussions of fiscal natures are verboten. NPR told the nation that Maine doctors, who had the foresight years ago to commune regularly to create sensible, standards of care, would debate anything except money and its effects.

"It would have been a show stopper," said Bob Keller, a Maine physician who participated in these professional dialogues, told NPR. "It would have gone right to the question of greed, and you're not going to keep a doctor at the table if you say that he's greedy."

Nor would you keep a blacksmith, policeman or house painter, for that matter, if you accused them of being greedy. Greed is one of our culture's most despised personal qualities, particularly in professional fields — like medicine — where practitioners are called upon to adhere to higher standards of altruism.

This is probably why a majority of physicians support single-payer systems for health care, according to national polls. There is an instinctual reaction, and personal obligation, to separate the fiscal from medicinal, to avoid the aroma that money dictates decisions about care.

Except it does. Gordon Smith, the executive director of the Maine Medical Association, admitted this fact in the same NPR story, calling it both "common sense" and "human nature." How health care providers are paid for services affects how care is delivered.

The question is, what do we do about it? The standard answer is to regulate the payers: private insurers and government, most often. As policy, reforming the country's pilloried fee-for-service system and cutting its reimbursement rates are touted as the best way of "bending the cost curve."

Is it? Or would breaking the taboos of medicine to have honest, frank discussions about physicians and finances hold equal, or greater, promise? Discussions of money are nerve-wracking for providers, but in this ongoing national argument on health care, they are wholly unavoidable.

The issue is not greed, but rather holistic solutions. The American health care system cannot be repaired without acknowledgement and debate about how costs relate to delivery, and no group's expertise is more important to hear on the matter than physicians.

During the death panel rabble, we bemoaned the inability of the country to have an adult discussion about death. This same feeling is extended to money in medicine. Talking about it might be uncomfortable, but it must be done all the same.

editorialboard@sunjournal.com