Q: In my solo medical practice, I treat children from diverse socio-economic backgrounds. I don’t participate in any insurance plans, but I routinely use a downward-sliding scale to help parents in financial difficulty afford care. Many of my patients come from families with extremely high net worth. A friend suggested I charge them more. Is it ethical to use the sliding scale in both directions? NAME WITHHELD, NEW YORK
A: You already use the sliding scale in both directions, and reasonably so. To give one person a price cut is tantamount to giving everyone else a price increase. There is no sanctified price set by the gods as an unvarying standard of comparison: as long as people are paying variable prices, it’s all relative. If one person pays $90 for a service and another pays $110, whose payment have you reduced and whose raised?
Here’s another way to look at it: Surely, your fees have risen over the years. You’re not charging for a flu shot now what you did in 1810 (if you are a Faustian health care professional who will live for a thousand years and had there been flu shots in 1810). From that perspective, everybody’s fees have gone up over the past 200 years, some more than others.
If you thought about your fees in another way, as a percentage of patients’ income, you might conclude that you persistently charge wealthy patients quite a bit less than the needy. A bill for $10,000 — it’s a lovely nose job — represents 1 percent of the income of someone making a million dollars a year, but it is 33 percent of the income of someone making $30,000 a year. Why are you overcharging poorer patients? Why is someone with such a meager salary squandering it on a nose job? What was wrong with her old nose?
Finland assesses some speeding tickets not as fixed fines but in proportion to the violator’s income. Here in America, we accept other sorts of variable pricing. The cost of an airline seat can vary depending on when you buy it. The cost of a movie ticket alters with your age: kids and seniors pay less.
Despite there being no mathematically meaningful distinction here, psychology plays its part: it can feel different if you apparently lower a price — that’s generosity — than if you seem to raise one: that’s gouging. And so you should be transparent, perhaps appending a general statement to your bills: “Fees may vary with ability to pay.”
