Dr. Michael Fine: What’s crazy about health care and free food

Last Saturday, I went to try to help some heroic colleagues, who practice in one of Rhode Island’s poorest places, and who had set up a walking program called “Walking with the Doc” and a Saturday immunization clinic so that thirty local kids who had just moved into town could get immunized and start school on time—all great stuff. About fifty people showed up and walked with the doctors three times around a city park. As I was talking to one of the organizers, who not only provides medical care but also housing to homeless families in that community, I said something about giving out boxes of free fruits and vegetables at the next walking event, to encourage better nutrition. “Oh no!” my friend and colleague said. “We’re not allowed to do that. It might trigger a government investigation. And fines or even jail time.” “Surely you jest,” I said.

But she wasn’t jesting. The week before she’d been to a conference put on by some well meaning lawyers who gave her this information, and she checked and double checked this information and found out it was true. As we talked through my dismay and horror, I realized I already knew about the crazy situation she was describing, and I knew it was true. Medical practices can’t give anything away for free, even if they are serving the poorest people. Technically, medical practices can’t even discount their fees, or give free care to people who are uninsured, though many quietly break the law, as I knowingly used to.

What’s going on here?

Medical practices live in a fee-for-service world. Doctors, other clinicians, and practices get paid every time you come in to be seen. They use a standard set of charges based on the complexity of the problem to bill your health insurance, if and when you have insurance. Here’s where things get sticky. If a medical practice gives anything away, some lawyers and some regulators regard that free stuff serves as an inducement for people to be seen by the practice, understanding that every time someone is seen by a medical practice, that generates a bill that an insurer, Medicare, or Medicaid has to pay. So to the insurance and regulatory world, giving away free stuff can be seen as a way that medical practices can run the meter, and create more billing, some of which might, according to them, be unnecessary, at least theoretically, and create more cost – even if the free stuff is food, clothing and shelter, which some people desperately need, and even if those extra services are things like checking for and finding high blood pressure, or checking for and finding high blood sugar, among people at greatest risk for both of those problems. The lawyers and the regulators call this fraud and abuse.

The government and the regulators somehow can’t differentiate between the medical folks in poor communities, doing everything they can to help take care of poor people, and rich corporations, which do everything they can to profit off the misfortune of others, draining public funds into their own pockets in the process.

This fraud and abuse concept also explains why providing free care or discounting fees has become illegal, amazingly enough. Most medical practices (except psychiatrists and some others) accept Medicare, which is a good thing, because that gives our elders access to medical care. But Medicare has a rule: by Federal law, Medicare has to be offered the lowest price any medical practice offers. Which means that if your doctor doesn’t want to charge someone who is poor or down on her or his luck, that doctor has to offer to not charge for all their Medicare patients or risk bringing down the wrath of the government. And not charging for Medicare patients would bankrupt all those clinicians and practices.

The sad thing about all this is that the lawyers and regulators aren’t completely crazy. There IS lots of fraud and abuse in health care in the US. A few weeks ago, for example, United Health Care, one of the nation’s largest health care organizations, was caught sending nurse practitioners out to the homes of people with Medicare who had an insurance product called Medicare Advantage, so they could ask those people a series of questions, the answers to which let United claim those patients were sicker than Medicare previously thought. Those nurse practitioners didn’t do anything different for those people. They just reported new diagnoses, a process called upcoding. Upcoding isn’t illegal. It isn’t even clearly unethical, from a business perspective — it is, for United, part of what we have asked them to do to be a successful business, which is to maximize profit. But it nets United, and all the other health insurers who engage in these practices, billionsof dollars a year in public money, which turns into private profit, money they win for themselves just by gaming an incredibly complex healthcare payments system. So, there is a very good reason those lawyers and regulators pay attention to fraud and abuse. But that attention has unintended consequences.

We could fix this mess if we chose to, of course. The simplest fix would be to require that all health care businesses be owned by licensed health professionals, to use the licensure process and make it unethical for health professionals to profit from financial manipulations like the ones I just described, and then to pull the licenses of health professionals who act in this manner. (Some of us think this kind of activity is unethical now – but the licensure process is rarely used in this way.) Another fix: pay primary care clinicians by the month, not by the service, so we wouldn’t earn more by doing so-called nasty things like giving free food to poor people, and so there wouldn’t be any so-called fraud and abuse when decent clinicians act humanely.

Sixty years ago, a pioneering physician named H. Jack Geiger got national attention for his work in Mound Bayou, Mississippi, where he was prescribing food for malnourished kids. When there was an outcry and the governor of Mississippi criticized him for doing that, Jack pointed out that the well-established medical treatment for malnutrition was food, and he was just doing his job.

Today, my colleagues in Central Falls are just doing their jobs when they try to get people exercising, or when they think about giving away fresh fruit and vegetables to people who don’t have easy access to good nutrition. It’s crazy that they have to stop and think before they do more of that kind of thing. And crazy that our government and our regulators have to deal with the kind of profiteering that is rampant in health care in 2024.

Michael Fine, MD, is a writer, community organizer, and family physician. He is the chief health strategist for the City of Central Falls, RI, and a former Director of the Rhode Island Department of Health, 2011–2015. He is currently the Board Vice Chair and Co-Founder of the Scituate Health Alliance, and is the recipient of the Barbara Starfield Award, the John Cunningham Award, and the June Rockwell Levy Public Service Award. He is the author of several books, medical, novels and short stories, including On Medicine and Colonialism, Rhode Island Stories, and The Bull and Other Stories, You can learn more about Michael at www.michaelfinemd.com