Comments: Rip Off Inc

You do know that there's a lot of variation in physician incomes, no? And that, in general, spending time with patients pays poorly, but procedures pay well (that's why gastroenterologists make so much dough -- "scoping for dollars" -- while primary care docs make well less than half that). While it may be true that cutting MD incomes in half overall would be a good idea, we really won't accomplish anything without reforming the relationship between doctor pay and medical care.

And you're right, insurance company profits aren't the big problem -- it's their high advertising and administrative overhead, along with their duty as corporations to spend as little as possible on their patients' care.

Posted by guest death panelist at August 13, 2009 03:43 PM

Yes, that's why fewer doctors go into primary care these days. I think cutting by half is about the right amount. Of course it shouldn't be uniform.

The doctor-patient relation is abysmal. The entire practice of medicine needs to be changed drastically.

Posted by Bernard Chazelle at August 13, 2009 03:54 PM

The deluded folks who disrupt the townhalls are drawing attention from the actual failings of the "health care reform".
No "death panels", but also, no health care reform; which one do we hear about?

Posted by Murfyn at August 13, 2009 04:09 PM

I remember a story - possibly apocryphal - about the head of the British national health service being asked how he would win the consent of doctors and hospitals to the establishment of national health care back in the 1940's, and his reply was: "I'll stuff their mouths with gold." In other words, you agree to high payment rates in the short term to get the program underway, and then gradually cut rates (or even just restrain the rate of growth) over the long term. Fifty years later, you've got a system that pays considerably less that it would have for health care.

In short, there's no reason to make cuts in reimbursement rates for doctors and hospitals a precondition for "meaningful" reform.

Posted by SteveB at August 13, 2009 04:28 PM

SteveB: Agreed. You could have single-payer or have a public insurance system that pushes the private insurers into a supplemental/boutique role (like in France). At that point, the government can dictate prices. You can't put a gun to doctors/hospitals and take them to take a cut. But you can easily do it indirectly. Same with Big Pharma. They use a divide and conquer strategy. They can't do that in Europe because the government has to approve their prices.

I think the case of Big Pharma is especially egregious because most of their research is funded by the taxpayer.

Posted by Bernard Chazelle at August 13, 2009 04:45 PM

Murfyn:

A Mickey Mouse reform (which is a virtual certainty) could actually be worse than no reform at all, because it would push any future reform attempt to the next, huh, millenium at the earliest.

Posted by Bernard Chazelle at August 13, 2009 04:50 PM

In regard to time spent with patients, there was an article here (Cleveland) recently that doctors working for the Cleveland Clinic system (several outpatient clinics throughout the area) would now be required to see four patients per hour instead of the current two. But since then no info. This is apparently a policy a large institution can implement, unlike an independent clinic or just plain doctor's office. How many of the former two such places are there anymore, if any?

Posted by catherine at August 13, 2009 05:08 PM

Steve, you're thinking of Aneurin Bevan.

Posted by Jonathan Versen at August 13, 2009 05:44 PM

Bernard, I'm glad to see you say this:

"I think the case of Big Pharma is especially egregious because most of their research is funded by the taxpayer."

It is also what I find most reprehensible. But it's interesting, I find it tremendously hard to get other people to understand this. Do you find the same thing?

I wonder whether it's necessary to be a scientist performing government-sponsored research to understand this.

Posted by Aaron Datesman at August 13, 2009 06:47 PM

@Aaron: Besides the standard answers (corporate media conditioning etc.) ... maybe it's that for most people, technology might as well be magic, because they're not interested in how infrastructure is configured? I mean, I see a box of medicine on the shelf at a store (or a computer for that matter), and it has a certain price, and since I've seen the same thing since I was an infant, I tend to accept that price and not think about the chain of research and scientific knowledge which got it there ...

Posted by Cloud at August 13, 2009 07:28 PM

Yes, Aaron, you keep hearing this nonsense all the time. What people don't want to hear is that one reason US science is the best in the world is that it's run as a socialist organization funded by vast amounts of tax money. And corporations benefit hugely from that system. Interesting that the one thing that works the best in America (science) stands in complete violation of free market principles.


Posted by Bernard Chazelle at August 13, 2009 07:44 PM

"Doctors, hospitals, and pharmaceuticals make too much money. (So do, to a lesser extent, health insurers, but they have another problem: they're incompetent.) Until the government forces all these folks to cut their incomes by a half, there won't be any meaningful health care reform. And that's why there won't be any meaningful health care reform."

--"to a lesser extent, health insurers. . ." Is that a joke? Doctors and hospitals are NOT making more money than health insurers. I agree health insurers are wasteful, and I'd add no good too, and their executives are really making HUGE amounts of money.

--If "meaningful" health care reform means that all powerful interests with a lot of control over the outcome have to agree to cut their income in half, that certainly won't ever happen. So let's all try to do that!

Posted by N E at August 14, 2009 09:49 AM

It's not so simple. In my own relatively small practice we have 3 people employed only for billing, which means all-day-long interfacing with insurers, from authorizing insurance payment before the study is done, to trying to collect after the fact. You'd be surprised by the numerous hoops the insurers make you jump through on every case. They have created this labyrinthine system not because it protects patients but simply because they don't want to pay for exams ordered by physicians on their customers, and one mechanism by which they accomplish this is by making authorization of even the most routine testing a difficult process requiring billing code expertise and lots of online/phone time. It's a joke, a huge superfluous layer of encumbrance.

(Partly as a result of inefficiencies, the health care system is also a huge jobs program, although no one likes to admit this. I've no doubt that nowadays in many towns and small cities, the local hospital is the largest employer in town).

As for doctor salaries, keep in mind that the doctors that make the most typically work incredibly hard, harder than their colleagues, year after year, decade after decade, and (gasp) are also the doctors who are best in their field in their community. Specialists make more because their training is longer and, if they do procedures, they have to be good at what they do. A few missteps and your career as a proceduralist will be over. Not to knock my primary care colleagues overly much, but as long as you smile at grandma and pat her hand, even if you are mistaking her congestive failure for asthma, no one will be the wiser. But ligate the hepatic artery instead of the cystic duct in a routine lap cholecystectomy and you, friend, are fucked.

I have a partner who makes over a million a year. Awful, right? You know what makes it worse? He's an immigrant! But he works weekdays from 4 am to 10 pm, works weekends, never takes vacation (well, 2 weeks the past 8 years, lazybones), and does, every day, twice the work of "average" physicians in his field. He has so much work because he is incredibly good at what he does, and also (they don't always go hand-in-hand) provides excellent service. Under what arbitrary metric would you cut his pay in half? Would you tell him to keep banker's hours? Take more vacation? Or just cut his reimbursement per case from $60 to $30?

You can do that, sure, but at some point the good doctors will say 'screw it, I'll go play the guitar or read Wodehouse or something else enjoyable,' and you'll be left with the mediocre doctors, the ones just out of training (who make less than the fastidious drone workaholics who have built up their practices over 10-20 years), who make more mistakes and harm more people, but hey, at least they make less.

Anecdote time: I once did a spinal angiogram on a patient that required 28 separate, so-called "selective," arterial injections (via the aorta, duh). Each selective injection was a "billable" event. We found the source of the patient's paresis on the final injection, the median sacral artery, which was supplying a spinal AVDF. The patient went to surgery and was cured. Yay! The hospital billed over 12k for that single procedure. They got reimbursed less than 2k from the insurer.

I've now stopped doing arteriography: it wasn't worth the time, stress, and radiation exposure for what it was paying. There is now no one locally who can do a spinal angiogram. Luckily, it's a rare procdure, so not a big deal, but patients requiring the study need to travel to the nearest large city to have the procedure done at a teaching hospital, which often means they'll have a Fellow-in-training mucking about in their aorta for hours, trying to locate the spinal vessels, with attendant higher complication rates. But good training for the boys, and Fellows only make like 50k, so what a bargain for the patient! Except not really: teaching hospitals bill more than I would have, since they have to cost-balance and have WAY more overhead.

Medicine, particularly when it comes to interventional procedures, necessitates skill, commitment, and experience, if the success rate is to be high and the complication rate low. Next time you're facing brain surgery, insist that the surgeon be payed half his normal amount, and be sure to tell the surgeon, who probably makes well over 500k/yr, that he is "overpayed."

(BTW, I knew neurointerventionalists in Paris who bragged about making over half-a-million Francs or more, back in the 90s.)

Don't generalize. You can't compare a clinic generalist with a specialist, particularly a surgeon. Big difference in skill set and responsibility. If surgeons make what a family doctor makes, they won't become surgeons, they'll become family doctors--it's easier, you have more time with your own family, more time for hobbies, shorter training (by years), lower malpractice.

It's not about health care providers, it's about the MIC robbing the country blind to pay for foreign imperialism. Bring the troops home, end the wars, we can easily afford to give health care to everyone. Please, no half-cocked fulminations: it's a distraction from the main problem: Empire.

End rant. But I have a question: Bernard, what percent of GDP should a nation be spending on health care, and why is it immoral to spend more than that percentage?

Posted by Terumo at August 14, 2009 10:59 AM

Highlighting some quotes from that NYT article:

“Our proposals would change incentives so that doctors and nurses finally are free to give patients the best care, not just the most expensive care,”

I.e., care befitting denizens of a third-world nation. Next time you want a cardiac cath, insist the angio unit be a cheaper, Czech made unit, not one of those pricey German or Dutch jobs.

"Many doctors who work at Bassett believe deeply in its mission. Bassett has opened 13 clinics in schools around the region. The clinics lose money, but Bassett is considering opening 14 more."

Absurd. Who pays for the losses? Someone has to. Ponies for everyone!

"Dr. William F. Streck, the longtime president of Bassett, said the hospital paid salaries that were competitive with the money earned in a fee-for-service setting. Some fee-dependent physicians, though, either by working hard or by providing excessive treatments, can make more, an ability doctors trade associations have long defended."

Doctors who "provide excessive treatments" are guilty of malpractice and should be identified and punished. Aspects of the current system, such as orthopods owning their own MRI and doubling standard utilization rates for their own profit, should be stopped (cutting out Stark loopholes, in radiologist-speak).

But what about the doctors who make more by working hard? How does Bassett deal with those unpatriotic individuals?

No answer.

I'm familiar with Bassett, and know rads who work there: in my field, the pay scales were subpar, and they couldn't attract top people. It's an isolated hospital in the middle of nowhere (Cooperstown), with a nice homogenous population base (similar to the Mayo Clinic in Rochester), not translatable to urban America.

"Everyone knows that the Bassett model is the right model,” said Senator Charles E. Schumer..."

When politicians say "everyone knows," my skepticism-meter gets pegged.

Posted by Terumo at August 14, 2009 11:15 AM

Terumo: EXCELLENT 2 posts. I sincerely hope someone like YOURSELF is part of the policy process in Congress.

Posted by Mike Meyer at August 14, 2009 11:47 AM

I agree the MIC is a more serious issue, but why should health providers get a pass? They're making tons of money for delivering a mediocre service.

Your quote about the French doctor is obviously wrong (did you mean euros?), but if you were trying to say that some French doctors are making tons of money then yes that's true. France has private insurers and what's called "nonconventioned" doctors who charge anything they want. But they're a tiny minority and I have no problem with that.

>> But he works weekdays from 4 am to 10 pm, works weekends, never takes vacation

Are overworked doctors a good thing for patients?
And why is he doing it? For money? Or because he loves the practice of medicine so much that he can't stop?

What percent of GDP should a nation be spending on health care, and why is it immoral to spend more than that percentage?

That's my point about free markets. Ultimately a country can spend 100% of its GDP on health care, because health has no price. There's not a single item you own you won't sell to save the life of your child. The immorality is that the medical establishment exploits that to enrich itself.

Re. training, yes heart surgery requires a lot of training, but so what? It requires much less training than being, say, a cutting-edge classicist, who might be teaching Latin and doing research in Greek poetry at North Dakota State and make 80K a year. So the training argument leaves me unimpressed.

As to the argument that everyone would become primary care doctors if not for the enormous salaries of specialists, that's provably false. Look pretty much anywhere in the world, except the US, for a proof.

The point about insurance companies is that they're so incompetent their profit margins are not that high. But yes top executives are way overpaid.

How do you get doctors to make less? You have the government run the bulk of the insurance business and cap reimbursements. This way, doctors will be forced to choose between running boutique operations and charging what they please or accepting the official rates.

Here's the thing. To have a decent health care systems is hardly rocket science. Every advanced society has something semifunctional, except the US. So this is like discussing indoor plumbing.
I think we know the answer.

Posted by Bernard Chazelle at August 14, 2009 01:26 PM

Thanks, B. A few points...

>>I agree the MIC is a more serious issue, but why should health providers get a pass? They're making tons of money for delivering a mediocre service.

Again, you're generalizing. Not all doctors deliver a mediocre service. Some deliver outstanding service.

>>Your quote about the French doctor is obviously wrong (did you mean euros?)

That's what the French doctor told me. Wasn't France still on Francs in the early 90s? (conversion in 99?). Presumably he was a "private" doc.


>>Are overworked doctors a good thing for patients?
And why is he doing it? For money? Or because he loves the practice of medicine so much that he can't stop?

He's brilliant, and able to do it without mistakes. He is much better than his less-ambitious confreres. He does it for the money (although he likes what he does).


>>That's my point about free markets. Ultimately a country can spend 100% of its GDP on health care, because health has no price. There's not a single item you own you won't sell to save the life of your child. The immorality is that the medical establishment exploits that to enrich itself.

True. We make money off people's sickness. We also, unfortunately, cause a lot of illness. That's why 'primum non nocere' is so crucial, the sine qua non of medical ethics.

>>Re. training, yes heart surgery requires a lot of training, but so what? It requires much less training than being, say, a cutting-edge classicist, who might be teaching Latin and doing research in Greek poetry at North Dakota State and make 80K a year. So the training argument leaves me unimpressed.

Mistranslate a line of Pindar, no one cares much, it's a mistake that can be corrected at leisure. Not the same as making an error in surgery. Nothing "noble" about it, just reality. That takes nothing away from what classicists do. (My hero is Hugh Kenner.) Plus, do classicists really train 15 years before "practicing?"

But I agree with the sentiment. Poetry will save the world, not molecular biology.

>>As to the argument that everyone would become primary care doctors if not for the enormous salaries of specialists, that's provably false. Look pretty much anywhere in the world, except the US, for a proof.

Tell me where to look. Canada? France? India? China? I think surgeons make more than primaries in all those countries. In Canada, per 2006 figures, specialists in Quebec averaged 280k, versus generalists at 230k. (Generalists seem to make out ok in Canada, eh?) But your point is taken. Some people would become specialists to have greater control over their practices, others for the prestige, or fascination with some narrow aspect of medicine.

>>The point about insurance companies is that they're so incompetent their profit margins are not that high. But yes top executives are way overpaid.

>>How do you get doctors to make less? You have the government run the bulk of the insurance business and cap reimbursements. This way, doctors will be forced to choose between running boutique operations and charging what they please or accepting the official rates.

Doctors accepting medicare, medicaid, and private insurance don't get to "charge what they please." They get reimbursed according to what the fee schedule is for the payer. Medicare, which is the bulk of my practice, has extremely well-defined reimbursement codes, utterly blind to quality of service, which vary by region as a nod to cost-of-living. So it's not clear how single payer or any other model would change that.

If you're a cosmetic plastic surgeon (or chiropracter, hey, just sayin') it's out-of-pocket payment, so yes, I guess you can charge what you like. Single payer won't pay for that, anyway (I'd like to think).

>>Here's the thing. To have a decent health care systems is hardly rocket science. Every advanced society has something semifunctional, except the US. So this is like discussing indoor plumbing.
I think we know the answer.

It's a stretch to say that the U.S. doesn't have a "semifunctional" health care system. They're doing something in all those hospitals every day, Bernard! But yes, for a lot of people, health care is too expensive, even unaffordable. So is good legal representation, good food, housing, and petrol. Something's got to give, no argument there.

Mike Meyers, the chances of me being involved in health care reform are slim to none. I haven't paid the current debate much attention. I think, as a start, all children (pick your age limit) should have free insurance. It's amazing to me that they don't. But I also think abortion is an economic imperative for a lot of people, so depriving children of life because of economic exigencies is in keeping with depriving them of health care because of economic exigencies. The bottom line, which you and I both understand, is that the U.S. doesn't care much about human life, either for its helots at home or the unfortunate recipients of the gift of Democracy abroad.

Posted by Terumo at August 14, 2009 03:50 PM

Terumo: NO question ALL childern should be covered, free or otherwise. No matter what a doctors wages are I think WE can agree they'll NOT be free. SOME form of payment needs to be found. I feel the insured SHOULD pay if financially able and the MORE able, pay more.

Posted by Mike Meyer at August 14, 2009 04:05 PM

Terumo, we still still seem to be talking about indoor plumbing as Bernard pointed out. Every industrialized nation on earth provides medical care cheaper and with demonstrably better results than here in the US. A constant in the other systems is some variation of single payer. I mean really, this isn't that difficult.

Posted by Coldtype at August 14, 2009 04:19 PM

Coldtype:

Oh, I have no problem with single payer. The rich will still carve out a private market, like in France and England, roughly 10%, as Bernard notes. But there will be a large additional layer of government, claims adjustors and the like, telling doctors and hospitals what they can and can't do.

Take an easy example, the medical equivalent of shooting fish that have already been killed and fried. Sudden onset of low back pain. Right now, most people with insurance, and anyone over age 65, can go see their doctor, in some states even their chiro, and get an MRI to see if they have a big disc, or maybe a tumor. Have a look, you know. But the vast majority of the time there is nothing significant on the scan, nothing "surgical" or that would progress (such as a tumor). Studies have been published, including by prominent academic neuroradiologists, that show that there is MRI scanning in the first 6 weeks after onset of back pain is not efficacious. It's not cost-effective, and adds nothing in the end to patient management. Yet, routinely, patients get MRI scans if they have new onset back pain.

It is easily within the realm of my imagination that a sub-department of a government task forth on imaging, an arm of the single-provider, would look at this data and come to the conclusion that Americans enrolled in this plan are not authorized to have MRI scans in the first 6 weeks after developing back pain. Makers of MRI equipment, my own specialties' lobby, would argue against such a rule change, but they would lose, particularly in an environment where the government is broke.

Statistically, there'd be no harm. Early scanning isn't particularly useful or cost effective. Would a subset of patients have benefited from the scan, early discovery of a tumor, or large disk fragment? Sure, a few, and when you're talking millions of people with back pain, more than a few, but still, for the greater benefit of the population, routine ordering of MR scans in this setting would stop.

I would lose income under this model. But hey, new paradigm. I'd benefit in other ways. If we were really to go through the whole system in an intelligent fashion, looking (as we say) at Outcome Based practice, we'd save an enormous amount of money. If that's coupled with an intelligently-run single-payer system, great.

My example of low back pain is a no-brainer, right, not too much to lose? But the same analysis is going to be applied to every single aspect of medicine. There will be specific criteria for everything: who gets a cardiac stent, who gets pain killers, who gets a cast versus splint, who gets the more expensive antibiotic, and in each instance there will be individuals who might have benefited from intervention or alternate treatment but who didn't receive it. Currently, private insurance in the US allows a large number of people to receive the benefit (even if getting paid is not always easy on my end): single payer won't.

But looking at broad criteria like "average life span" won't ever tell you that. It's information, but it tells you nothing about the individual.

Best way to stay healthy is to eat lots of vegetables, stay thin, exercise, and avoid doctors. In France, I think in the 80s, when doctors went on strike, mortality rates dropped.

Posted by Terumo at August 14, 2009 05:23 PM

Terumo, thanks for your contribution, it's very interesting. Generally I'm so intimidated by Bernard that I never question anything he writes!

You think that, for a start, all children should have insurance? I think that this is excellent!

I'm not religious, but I like this idea: we're all children of God.

Posted by Aaron Datesman at August 14, 2009 05:29 PM


Terumo: Thanks very much for sharing all that. It's very useful for me to see the informed, thoughtful opinions of a doctor who doesn't have an angle or an axe to grind, because I really don't understand how any of this would work in practice.


Aaron Datesman:

You wrote: "Generally I'm so intimidated by Bernard that I never question anything he writes!"

--I could help you get over that. Or maybe you could just post "Bach sucks!" a few times and see whether BC finds you and murders you. If not, you'd realize that nothing else you said could ever put you in real danger. Of course, he might . . .


Posted by N E at August 14, 2009 07:19 PM


Terumo: Thanks very much for sharing all that. It's very useful for me to see the informed, thoughtful opinions of a doctor who doesn't have an angle or an axe to grind, because I really don't understand how any of this would work in practice.


Aaron Datesman:

You wrote: "Generally I'm so intimidated by Bernard that I never question anything he writes!"

--I could help you get over that. Or maybe you could just post "Bach sucks!" a few times and see whether BC finds you and murders you. If not, you'd realize that nothing else you said could ever put you in real danger. Of course, he might . . .


Posted by N E at August 14, 2009 07:19 PM

AGREED there will be review of proceedures and SHOULD be to avoid excesses and outright fraud. Any policy, to avoid jealousness between percieved Haves and Have Nots, should PAY FOR WHATEVER DOCTOR AND PATIENT AGREE UPON for treatment or cure.

Posted by Mike Meyer at August 14, 2009 11:12 PM

TO PAY FOR SINGLE PAYER simply CHARGE THE POLICY HOLDER enough to cover costs. THAT'S what insurance companies do, ONLY instead of sending the CEO AND all the guys and gals of the office on a world rockstar tour, INVEST their rock&rollparty slushfund into T-bills=its OWN trustfund.

Posted by Mike Meyer at August 15, 2009 01:12 AM