Simple solution

If you haven't been to a doctor lately, you'd better fasten your seat belt. American medicine has been undergoing a rapid transformation likely to shock those who still believe frugality is a virtue. My awakening came the other day when I went to the doctor to have removed a small sore on my leg that hadn't healed. I assumed it would involve one quick office visit costing around $100.

My first surprise was to find myself not in a doctor's office, but in the suites of a regional dermatology firm that had at least five doctors and was headed up by a CEO. They were bemused at the counter when I told them I didn't have insurance, declined to use Medicare, and intended to pay out of my own pocket.

In the examining room, a doctor looked me over. The sore couldn't be removed yet, he said. He had to take a biopsy. He injected a little anesthetic and took the biopsy. The receptionist handed me the bill: $1,080. All the joy instantly went out of my life.

Back home, I took a close look at the bill and saw how each action had become an expensive, itemized procedure. When the doctor looked me over, he called it an "evaluation," costing $165. Taking the biopsy involved three separate charges, of $175, $129, and $169, and so on.

At the second visit, while waiting for my treatment, I asked the nurse, "Why couldn't we remove all the tissue in one visit, instead of going through a biopsy?" I pointed out that I was paying for everything myself and wanted to keep costs down.

"Medicare requires it," she replied. "We can't get reimbursed unless we can prove that we removed cancerous cells."

"But since I'm not on Medicare, couldn't we have skipped that step?" She wasn't sure that was possible.

My conversation did bring a benefit. When the doctor came - a different one - the nurse explained to him that I was paying out of my own pocket, leading him to suggest a simpler surgical procedure, one that might involve a larger scar but cost $490 less. I took the scar and the $490. Even with this reduction, my total bill for both visits came to $1,419.

While I was going through this introduction to gold-plated American medicine, I happened to talk with Wanda, an acquaintance who works in an unusual medical practice. She is office manager for a doctor - her husband - at a small, walk-in clinic that operates on a cash-only basis.

"You mean you don't take any insurance payments or government subsidies?" I asked. "How is it possible for you to survive?"

"Well, you know, we're not out to make a lot of money. We have a small house. We live modestly."

"So what do you charge?"

"Our office visit is $30, and we use a sliding scale for other procedures," she said. "Say a single mom comes in, and you know she can't pay a $100 charge. I ask her, 'how much can you afford?' The mom says, '$50,' and then I say, 'How about $40?'" Wanda gave a cheerful laugh, "So everyone's happy."

"How often do you adjust patients' bills in this way?" I asked.

"We do it with about half of them."

I was stunned. What an amazingly simple way to achieve affordable health care! In this arrangement, the doctor informally shifts the burden to wealthier patients (and to himself). It is one of many voluntary systems for making healthcare affordable, systems that include faith-based charity clinics and alternative medicine.

Wanda mentioned that her husband pays $12,000 a year in medical liability insurance, and that gave me an idea: Exempt from the liability system those practitioners who don't accept government subsidies or third-party payments. This measure would encourage low-cost, patient-oriented practices that emphasize personal responsibility, generosity, and common sense.

Sadly, this kind of reasonable reform would be hated by the special interests who now control the system, the trial lawyers, big business, big medicine - and policy wonks convinced that more big government is the only way to fix the institutions they have broken.

James Payne, author of Six Political Illusions, has taught political science at Yale, Wesleyan, Johns Hopkins, and Texas A&M