Universal Coverage –Why Massachusetts is the Last Place to Begin the Experiment

At the Massachusetts Medical Society’s 8th Annual Leadership Forum last Wednesday, Dr. Steven Schroeder, former head of the Robert Wood Johnson Foundation
and Distinguished Professor of Health and Health Care at the University
of California, San Francisco, told a provocative story about a poll
that asked patients in the U.S. `Canada,  Australia, New Zealand and
the U.K the following question:

“If your personal doctor told you that you had an incurable and fatal
disease, would you accept that diagnosis or seek a second opinion?

  • In the U.S.           91 percent of patients said they would seek a second opinion.
  • In Canada            80 percent                    “        “       “       “     “     “           “ 
  • In Australia          71 percent                  “        “   
  • In New Zealand     51 percent
  • In the U.K.           28 percent 

“You have to love the British,” Schroeder commented. “You can just hear
an Englishman saying ‘Well, Luv, it’s been a good life, hasn’t it? Now
let’s make a pot of tea and discuss the funeral arrangements.”

At the other end of the spectrum, we find the Americans who, Schroeder
noted, “are the only people in the world who expect to live ‘in

Today, I would like to suggest that our expectations as patients help
to explain why we spend roughly twice as much per person on health care
as most developed countries—even when, overall, it’s not clear that our
healthcare is better. In fact, in some areas outcomes are worse.

Schroeder listed the factors that drive our health care bills ever higher: as a nation, we consume more care than the citizens of other countries while also paying more for virtually everything from devices to specialists. We don’t spend more days in the hospital—in fact, our hospital stays are usually shorter—but more happens to us while we’re there.  We use more cutting edge medical technology.

U.S. patients also undergo more procedures. Just one example: in the U.S. 388 out of every 100,000 people has a coronary angioplasty procedure, compared to 166 out of 100,000 in Germany, 81 out of 100,000 in Canada and 51 out of 100,000 in England.  Now, we may have more heart disease than some countries—but not that much more. (In fact, given the fact that many European still smoke, and not a few drink wine as if it were water, we might expect the rate of heart disease to be higher there.)  Meanwhile, research shows that, even as we open more cardiac centers and do more angioplasties we have seen little improvement in the percentage of patients who survive heart attacks since 1996. Yet spending in this area continues to spiral. Clearly we have reached a point of diminishing returns.

The U.S. also has more intensive-care beds than other countries, Schroeder noted—which led to another story. He described how surprised he was when he first visited intensive-care units in Europe. “There weren’t nearly as many beds—and the ‘train wrecks’ weren’t there,” he said, referring to patients who are so seriously damaged by disease or accident that it seems extremely unlikely that they will ever recover.

“I asked ‘Where are the train wrecks?’ Schroeder recalls, “and the students and doctors looked down at their shoes. Finally, someone spoke up, said he had trained in the U.S., and admired so much about U.S. medicine, but he said, “You don’t know when to stop.”

Part of the problem may be that American consumers want and expect more health care. We just won’t accept our own mortality: we expect medicine to save us. Indeed some, like medical ethicist Daniel Callahan, have suggested that our high-tech, high-profit health care industry is “in the business of selling dreams.”

But few seriously ill patients call out for the opportunity to spend their dying days in an ICU. Most would prefer to die at home. True, their relatives may well urge the ICU nurse and doctor to “do everything possible,” but that doesn’t explain why so many U.S. patients land in an ICU.

Research suggests that some Americans spend more time in ICUs than patients in other parts of the world, in large part because we have more ICU beds.  In other words, supply drives demand. And what is true of the U.S. as a whole is true of Massachusetts, in spades.

Just as the U.S. spends more per person on healthcare than any other country in the world, healthcare expenditures in Massachusetts surpass spending in every other state.  And this, I propose, is why Massachusetts is having such a hard time implementing its new healthcare reform law.

On Friday I wrote about the problems that the Massachusetts plan is facing. In an effort to achieve universal coverage, Massachusetts has mandated that everyone in the state must purchase health insurance; those who earn less than 300% of the poverty level will receive a full or partial subsidy from the state to cover the cost of premiums.  Those who are receiving a subsidy have responded enthusiastically, and are signing up. But people who don’t qualify for the subsidy are refusing to buy health insurance. They would rather pay the fine. Thus, of the 228,000 uninsured citizens that the state hoped would sign up for insurance, just 15,000 have enrolled. Many say that the insurance is just too costly.

Today let me suggest why insurance is so expensive in Massachusetts.  It’s not because the insurance industry is profiteering in Massachusetts—or at least, that is  not the major problem. Unlike most states, Massachusetts is blessed with a large number of non-profit insurers, and by and large, the state’s reformers say, insurers in the state made a good faith effort to design affordable policies for the program.

Insurance is expensive in Massachusetts because its citizens consume more healthcare than people in many other states.  They undergo more tests and procedures than most of us, and they see more specialists.  Look at a graph of average healthcare expenditures per person in Massachusetts compared to average healthcare expenditures in the rest of the U.S., and you find that in Massachusetts, individuals receive an average of  nearly $10,000 worth of care each year—compared to just a little over $7,000 per capita nationwide

Do the citizens of Massachusetts expect more care than Americans in other states? Probably—after all, that is what they are used to. If they didn’t receive extremely intensive aggressive care, they might think something was amiss. Doesn’t the doctor like me? Doesn’t he care?

But the underlying reason people in Massachusetts have become accustomed to such lavish care is not that they are naturally more demanding than people in other states.  Rather, high consumption of care is driven by the fact that the state is a medical Mecca, crowded with academic medical centers, specialists and the equipment needed to perform any test the human mind is capable of inventing.

How can I speak with such confidence about what drives health care inflation in Massachusetts? Because over the past three decades, researchers at Dartmouth University have been analyzing Medicare records in various parts of the country, and found that Medicare spends twice as much per person in some areas than in others. And researchers have discovered a direct correlation between how many specialists and hospitals beds are available in the region and how much Medicare spends. Build the beds, and they will be filled. (I have written about the Dartmouth research here)

To understand why it is so hard for Massachusetts to fund universal coverage, begin by looking at Medicare spending in Massachusetts. The records reveal that in the Commonwealth, Medicare spends roughly $7,000 per beneficiary each year—40 percent more than it spends in states like New Hampshire, Utah, Oregon, Montana, South Dakota or New Mexico, and 16% to 25% more than it shells out, per senior, in Vermont, Maine, Wisconsin, Virginia, Colorado, North Carolina, South Carolina, Ohio, Iowa or Minnesota.

Is this because seniors in Massachusetts are sicker than people in Iowa or Minnesota? Is it because Massachusetts doctors charge more? No. The researchers adjusted for differences in local prices, race, age and the overall health of the population in each region. 

Yet the quality of care is no better in the states where Medicare spends most, according to a 2004 study published in Health Affairs.  Frequently, it is worse.  According to the study, quality (measured by using 24 yardsticks of effective care developed by the Medicare Quality Improvement Program) appears highest in Northern New England states (New Hampshire, Vermont, Maine) and Northwestern states (including North Dakota, Wisconsin and Minnesota) where Medicare spends only about $5,000 per patient each year.

Researchers have concluded that this is because so much of the healthcare consumed in high-spending regions is unnecessary. This is care driven, not by medical need, but by supply. By definition, overtreatment exposes the patient to more risks than benefits—or  as Dr. Elliot Fisher, one of the Dartmouth researchers, puts it, “Hospitals can be dangerous places, especially if you don’t need to be there.”

Now consider supply in Massachusetts. It turns out that the Commonwealth has one doctor for every 267 citizens of the state—versus one doctor for every 425 people in the nation as a whole. Meanwhile, the state has a critical shortage of primary care physicians—and an abundance of specialists.

Thus, there are more specialists available to see patients—and they do. During their last six months of life, slightly more than a third of Massachusetts’s patients see 10 or more specialists. By contrast, in Maine, Vermont and Oregon fewer than 20 percent of patients are attended by a bevy of specialists. 

Massachusetts also has an abundance of hospital beds—enough to allow patients to spend an average of 11.8 days in the hospital during their last six months of life—compared to 9.5 days in Maine.  None of this is consciously planned. It’s just that if the beds are available, it’s easier to hospitalize the patient. And once they are in the hospital, it’s easy to refer them to a dozen specialists, assuming that enough specialists are available.

In my next post, I’ll talk about my own speech at the Massachusetts Medical Society’s Forum, and why I held out hope that it will be possible to finance universal coverage nationwide—even if Massachusetts was a tough place to begin the experiment.

23 thoughts on “Universal Coverage –Why Massachusetts is the Last Place to Begin the Experiment

  1. First I would like to say that it is an over simplification to assume that Americans would like to live perpetually because they would get a second opinion, in fact I think it is more evident of the erosion of a trusting doctor-patient relationship. I am more likely to get a second opinion when my treating source is a stranger who I have to make an appt three to four weeks ahead of time, sit in his/her office while she is an hour late to spend 10 minutes not really listening to me. In my own practice, I have found when you take the time to explain and teach realistic expectations, patients make more reasonable choices about tests, referalls, and extensive care. Furthermore I think you have to consider the medical practioners fear of liability, we are not held to scientific standards (take the pretty much unproven PSA for example) we are held to “community” standards, which means if everbody in my town gets an MRI for a headache, I better order one too just to protect myself despite the fact I know it is a gross misuse of resources. Medical resources are not a bottomless pit, I fear we as a society will find that out the hard way. I trained in England for a while, and learned quickly how spoiled we are. Upon leaving the bedside of a “train wreck” one day the consultant (known here as attending) looked back and said, “she’s not for resusitation”. That was it, that is how the decision was made, no family discussion, nothing. I was initially shocked, but in retrospect it made perfect sense, it would be a hard sell in the, “I deserve everything available” US.

  2. Dr. Matt–
    You wrote: “In my own practice, I have found when you take the time to explain and teach realistic expectations, patients make more reasonable choices about tests, referrals and extensive care.”
    That, I think, cuts to the heart of the matter. Unfortunately, today doctors are not paid very well (if at all) to talk to patients, and to explain “realistic expectations.”
    But with health care reform I think this can happen–will have to happen.
    For that education to take place, “trust” is, as you say, essential.
    You’ll probably be interested in my next post, “A Transaction Based on Trust’ and what I have to say in the next day or so about “shared decision-making.”

  3. I know doctors dont get paid very much, I opened my own practice with the intention of providing that exact type of service to all who walked through my doors. I did just that, I actually spent time with people. Two years and three months later I closed my doors, now a mere $750,000.00 in debt, and bankrupt. I look forward to your next post.

  4. I read these comments and get the creeps.
    First, “Just as the U.S. spends more per person on healthcare…” Who is “the U.S.”? Can you point him/her/it out? Is it an alien from Mars?
    First thing to do to fix the “healthcare crisis” is follow the money; where, exactly, does it come from. And who, exactly, authorizes money to be spent on medical care. Finally, who actually gets/earns “health care money”? If we answer these questions truthfully and completely, the solution will, IMHO, be obvious.
    Second, the line: “…the consultant (known here as attending) looked back and said, “she’s not for resusitation”. That was it, that is how the decision was made, no family discussion, nothing.” That was so cold as to be frightening. The attitude of that consultant was, IMHO, the same as a rancher writing off a diseased head of cattle, worthless property to be disposed of.
    So sorry, but I am not a piece of worthless property to be disposed of for the greater good.
    When the medical arts stoop to that level, all is lost.

  5. Bobman,
    You should get the creeps, the problem in the UK in this case is they made the doctor also the “resource manager”. There is not an unlimited number of ventilators, or icu beds, I am afraid we are going to find this out in a crash. There will be an 11 year old girl who needs a vent from a trauma and it wont be there because nobody in the family of the 90 year old woman with brain damage and diffuse cancer understands that she is not going to get better. I think the UK method is horrid, but we will come to that if we all dont start to take some responsibility on when and how we use medical resources. I reiterate, it is not a bottomless pit!! If we as health care professionals only had time to spend with patients and families of patients. In my short lived practice I ushered more than 30 people to that goodnight, I spent endless conversations with family and loved ones. none of this time is reimbursed, not a single minute of it, despite the fact that it felt like some of my most important work.

  6. It’s a shame to see the poor healthcare reform in the United States, and Massachusetts situation is just an extension of the poor example the government is setting. Living on a fixed income can make paying increasing Medicare Premiums very difficult while big insurance is getting rich–utterly ridiculous! AARP set up http://www.thisissoridiculous.com so that we can sign a petition to make our voice heard. They also make it easy to write your Congressman to let him know how you feel. I’m working to support this with AARP, so let’s make sure we make our voices heard before it’s too late!

  7. Bobman, Dr. Matt and Paula–Thanks very much for your comments.
    First, let me try to answer Bobman’s questions.
    You ask “who is spending more than any other country on healthcare?”
    Of the $2 trillion plus that we spend on healthcare, 51% comes from taxpayers who pay taxes to fund Medicare, Medicaid and Schip (which account for 33% of our $2 trillion spending on healthcare), plus taxes to cover veteran’s hospitals, public hospitals and school programs (another 12% of the total $2 trillion). Taxes also
    pay for private insurance for government employees (another 6% of the total $2 trillion.)
    After taxpayers pick up 51% of the total bill, private insurance covers 30% of the nation’s health care expenses. Of course the money that private insurers pay out originally comes from premiums paid by employeees, employers, and individuals who buy their own insurance.
    Finally patients pay 14% of the $2 trillion out-of-pocket (in the form of co-pays as well as bills paid by patients who are uninsured or underinsured) and charity picks up %5 percent of the bill.
    You ask “Who authorizes these payments?” Congress authorizes the 51% paid by taxpayers.
    Medicare also plays a major role in deciding what is covered. When Medicare decides it will cover a particular drug or procedure, private insurers generally follow Medicare’s lead (and raise their premiums to cover the new cost.) Meanwhile, Medicare raises its premiums and co-pays to cover the new item.
    Congress would have the authority to tell Medicare that it can’t raise co-pays and premiums, but it doesn’t because a) lobbyists representing drug-makers, device-makers and some surgeons have a financial stake in seeing everything covered and b) the American public doesn’t understand how much waste there is in our system.
    Too often, we’re paying for over-priced, often unproven and ineffective treatments, but if anyone in Congress dared to suggest that Medicare shouldn’t cover something, voters would scream “rationing.”
    (Drug-makers, the AMA, et. al. have done a pretty good job of brainwashing the American public on this score, so most people genuinely believe that more care is always better care, and that the newest, most expensive treatment is probably better.)
    Bob also asks “who actually gets the $2 trillion? The answer to that is also in my book, “Money-Driven Medicine” (see pie charts at the beginning of the book labled “Who is Paying?” and “What Are We Paying For?”)
    If you look at what we are paying for, you find that 4.5% of the pie goes to private insurers to pay their administrative costs and cover their profits; 2.2% goes to cover the administrative costs of government programs like Medicare and Medicaid; 7% goes to nursing homes; 11% goes to cover the cost of prescription sold directly to patients in pharmacies [note this does not include the cost of drugs that you receive in the hospital or in your doctors’ offices–those costs show up on your hospital bill or doctor’s bill) 22% goes to physicians and for other clinical services; 22% goes to “other spending” which includes dentistry,home health services and over the counter medications, and finally, 31% goes to hospitals (that includes the money that the hospital takes as well as the money the hospital pays to device-makers and drug-makers which then shows up on your hospital bill as well as the money hospitals pay out for MRI equipment, etc.)
    Unfortunately, when you look at what we pay for, the solution is not obvious. There is waste in every area. And costs need to be contained in every area.
    I agree that decisions about who to resuscitate should be made in a thoughtful way. But often times the patient cannot be consulted–he or she is unconscious. And if the patient hasn’t made his wishes known (with a living will) then it’s up to the doctor to decide what to do, while consulting with relatives.
    Sometimes relatives refuse to let go. Studies show that middle-aged children are particularly reluctant to let an elderly parent die because when Mom or Dad dies, that removes a buffer between the middle-aged child, and the idea of death. If your parent dies you know that at some point you’re next.
    Meanwhile the elderly parent is often more ready to let go than the middle-aged child.
    This is where we need palliative care specailists to talk the relatives as well as the patient (assuming the patient is conscious)–counseling can help relatives accept the fact that it may be cruel to continue to do “everything possible.”
    Paula– Thanks for drawing my attention to the AARP site. You’re entirely right that Medicare premiums are rising too quickly. Part of the problem is that Medicare tends to cover anything the FDA approves, and these days, the FDA seems to be approving almost every new drug and device that manufacturers want approved–even if there isn’t sufficient evidence that benefits outweigh risks.
    The other problem is that Medicare Advantage is over-paying private insurers to provide Medicare.
    Private insurers are paid $10 billion more than Medicare itself would spend if it covered the same patients.
    As Dean Baker noted recently on http://www.tpmcafe.com :
    “The basic story here is straightforward. The insurance industry is too inefficient to compete head to head with the government in the Medicare program. If they have to compete on a level playing field, the industry loses.”
    In the original draft of the SCHIP bill, there was a provision that would have eliminated that $10 billion overpayment, but the insurance companies’ lobbyists quickly saw to it that this provision was removed from the bill.
    Dr. Matt–I hope that you’re still practicing medicine, even if you no longer have a solo practice.
    I think economics and the fee-for-service payment system make it very hard for a good doctor to keep a solo practice (or even a small group practice) afloat. As you say, you’re not paid to talk to and listen to patients, and this is often the most important part of medical care.
    If I were a doctor, I would greatly prefer to be on salary working for a good large hospital. Dartmouth-Hitchcock is one of the places I admire most because they put such an emphais on avoiding over-treatment and sharing decision-making with patients.
    (See the articles I have written about their work in Dartmouth Medicine, posted on the front page of The Century Foundation’s website–www.tcf.org.)

  8. Thanks Maggie,
    no, not practicing, hung up my stethascope with many tears, vowed not to pick it up until there is significant systemic change! If all my colleagues would do the same change would come quick! I live and work (and was born) here in NH. In my experience the educational centers are all better to work for as a doctor (I assume that is the dartmouth you mean, not the many factory style medical clinics in the state that tout dartmouth’s name). But alas, even they are not doing much to empower the doctors, the patients or change the sytem overall, they just do thier best to do the right thing (as I did) the difference being they have much more money than I did.

  9. Maggie, you’ve missed the implications of your own analysis.
    The core issue is demand. You obviously prefer to think of it in terms of some conspiracy involving “unnecessary” care. I prefer to assign responsibility to the patients who receive the services. Either way, it is demand that puts upward pressure on insurance and health care prices in Massachusetts.
    Where health care demand is concerned, Massachusetts is to the rest of the U.S. as the U.S. is to the rest of the world. This means that, unless our masters in Washington dictate how much care each patient receives, a universal health care plan for the whole country will have the same problems that the Massachusetts plan is having.
    The reason that people like Arnold Kling were able to predict the Massachusetts failure with such accuracy is because they did not look at the issue through the lens of ideology. They just did the math. And the math isn’t on the side of “universal” coverage.

  10. Catron,
    I must agree, before any national health plan can go forward somebody has to sit down and decide what exactly is standard health care. I am hoping botox and boob jobs are not in the final formulation. However I must disagree with demand raising prices/cost. First of all in medicine we only get paid what the insurance companies tell us we get paid, I could charge a million dollars for a physical, I will still only get the insurance comapanies “Maximum allowable benefit”, so it is probably the demand for insurance increasing the cost not the demand for health care (notably if the govt forces the purchase of health care that is likely to raise the cost for everyone). Also a quick study of economics will show you that two professions defy the supply and demand law, that is more supply actually increases the cost. In case you didnt already know, doctors and lawyers.

  11. Dr. Matt and Catron
    Dr. Matt– Wish you were practicing–the profession needs more people like you.
    But I suspect that whatever you do, you’ll be doing something imaginative and useful.
    Catron–It’s interesting that you mention Arnold Kling of the Cato Institute.
    As you know (because you commented on his post today at his website)Kling predicted that the Mass. plan would run into trouble because he, too, has read the research that shows that supply drives demand. Today, he quoted what he had written in 1995:
    “If I were going to pick a state in which to attempt an experimental health care financing reform, it would not be Massachusetts.” Kling continued: “Massachusetts,with its outstanding medical schools and world-class hospitals, is rich in the suppliers of premium medicine, and abundant supply has been shown to drive up usage.”
    As Kling goes on to point out: “It always amazes me how much consensus there is concerning the diagnosis of what is wrong with our health care system. Maggie Mahar and I agree that the problem is the extravagant use of medical procedures with high costs and low benefits. We agree that the U.S. is an outlier in the use of what I call premium medicine–specialists and high-tech equipment.”
    What’s interesting is that Kling (who, as I noted, is from the Cato Institute) is coming from his from a conservative point of view; I’m coming at it from a progressive point of view, and, yet as he says, we agree on so many points. (Though we don’t agree on the solution.)
    You, Catron, seem to be the only person in the room who looks at every issue through “an ideological lens.” (I say this based on comments that you’ve made when I blog on other blogs, not just here at HealthBeat.)

  12. Three points:
    First, Kling isn’t a conservative. He’s a Libertarian. There’s a difference.
    Second, by cherry-picking his comments, you have misrepresented his position. He does indeed agree with you (as do I, BTW) on the “extravagant use of medical procedures with high costs,” but he clearly disagrees with you on the demand vs. supply issue. Here’s the money quote:
    “I focus on the incentives on the demand side, particularly comprehensive health insurance. There, the Maggie Mahars of the world only want to put more people into the same incentive-distorting system.”
    And (third) that gets us back to my original point: mandated universal coverage ignores the underlying demand problem, which means it is doomed to failure, whether it is foisted on a single state or the whole country.
    The only way to control health care inflation is to control the demand for medical services. And you can’t do that by breathing down the necks of the providers. You have to put the patient in touch with the actual costs and take advantage of what Kling calls “opportunities that might be afforded by deregulation.”

  13. Ahhhh,
    51% of total health care costs are paid for by “the collective” (taxpayers via Congress). If you subscribe to the “equal blame via equal dollars” theory, Congress/taxpayers are 51% responsible for health care costs being “out of control.” They are not doing a good job.
    I’ve concocted a Einsteinian “thought experiment” you might want to try. Say the currently billed cost of one MRI scan is $2000. Does it really take $2000 to make that MRI scan happen, or is it just what the market will bear? If all the market could bear for an MRI was $50, would they stop happening? Or would the system adjust.
    Others have pointed out that the medical field is one where supply drives demand. Could that also happen on the money supply side?
    An example:
    Joe Smith presents with a combined $20,000 purchasing power, mostly government subsidized insurance.
    Jane Doe presents with only $500 purchasing power, personal savings only. If the patient population were forced into the Jane Doe mold (the vast majority of patients having meager purchasing power), would the medical system adapt or go out of business?
    Maybe the best solution is “no insurance, no how, no way”?

  14. The market adjusts, many pcp offices owned by large organizations lose money or just break even. They make it up with labs, xrays, speciality care etc. I personally like the idea of no insurance, and I think the whole health care system should go bankrupt. Extreme? yes, but it would bring meaningful change, and we would be forced to examine our values and priorities. This incremental change stuff is for the birds, and it doesn’t really seem to be getting us anywhere.

  15. BobMan–
    The health care market is different from other markets because the consumer has few choices. If your neurologist says: I’m concerned you may have a brain tumor, and you need to get an MRI–you get an MRI, whatever it costs.
    Research shows that when it comes to expensive medical services, high-co-pays have little or no effect on whether or not the consumer makes the purchase.
    He’s not in a position to delay the purchase, in hopes that a competitor will bring out a simliar less epxensive product.
    So medical technology only becomes more expensive over time.
    GE charges “what the market will bear” for MRI equipment–and the market will bear skyrocketing prices. IF a hospital doesn’t have the equipment, doctors will take their patients to other hospitals. And if a doctor says you need an MRI, you get it.
    Meanwhile, GE makes huge contributions to a “Cancer prevention Society” that lobbies Congress saying that everyone who has ever smoked should have regular CT scans for lung cancer (even though there is no proof that CT-scanning for lung cancer saves lives or extends lives.)
    In other words, while Congress and taxpayers pay for 51% of healthcare, the real power lies with the health care lobbyists.
    And that will probably continue to be the case until we have meaningful campaign finance reform . . .

  16. Unfortunately, today doctors are not paid very well (if at all) to talk to patients, and to explain “realistic expectations.”
    But with health care reform I think this can happen–will have to happen.

  17. America and Capitalism are both based on the freedom of choice. We as Americans and Capitalists should have the financial freedom to choose how we use our money, and we should be able to choose where we get a loan. The fact that certain states are banning a financial resource such as the payday loan industry is ridiculous. These states are taking away the availability of a loan to those who need money quickly, who don’t have the credit to attain one from a bank, who only need a few hundred dollars loaned instead of thousands. Don’t let the legislation take away your financial freedom and vote for your rights as an American citizen.
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  18. Being a doctor today is certainly not what is used to be, a path to riches. But, it that really why you got into the profession, or was it to help people?

  19. There are other reasons for needing emergency cash loans apart from being unable to pay regular bills, among them family deaths where the life insurance is insufficient to meet all the expenses. This is becoming more common as process rise while investment rates remain stagnant. The same is true at the other end of the life scale: weddings. These too can be high cost events that few couples or their parents have had the opportunity to plan for financially.

  20. Before, people would borrow from friends and family members, but this was embarrassing and many times took a while to collect the necessary funds. Today, that doesn’t have to be the only option. In fact, there is a better option and that is with payday loans.