Health Care Spending: The Basics; Spending on Physicians’ Services-Do We Spend Too Much? Part II

As part of a continuing series on health care spending, last week I looked at what share of our health care dollars goes to pay for physician’s fees and clinical services. As the pie chart below shows, 22 percent of the $2.1 trillion that we spent  on  health care last year went directly to doctors. That’s up from 19.4 percent in 1960.

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Most of the jump came in the 1960s and 1970s—though physician incomes continued to grow in the 1980s, rising 30 percent from 1984 to 1989, or about twice as fast as the average increase for other full-time workers.

I promised that this week I would publish a Part II to last week’s post and look at how much doctors are paid in other countries, how hard they work compared to doctors in the U.S., and how patients are faring as physicians’ incomes continue to outstrip both inflation and wages nationwide.  Finally, I said I would discuss whether we are spending too much on physicians services—and how we might change the way we pay them.

But first, let me very quickly re-cap the background to this story. In recent years, doctors’ fees have come under pressure. In the 1990s, managed care companies set out to pare costs by questioning virtually every bill that doctors sent them and in recent years Medicare has been trying to keep a lid on spending by refusing to raise most doctors’ fees.  Many private insurers have been following Medicare’s lead. Meanwhile, the cost of running a practice has been climbing, making it hard for some doctors (particularly primary care physicians) to stay afloat financially.

Nevertheless, by increasing the number of patients they see and the number of procedures they perform, many doctors have been able to boost their incomes.  More entrepreneurial doctors also have been making investments in surgical centers—creating a second income stream.  Thus, the overall amount that we spend on physicians’ services continues to rise: up 6.2 percent in 2000, up 8.3 percent in 2003, up 7.3 percent in 2004, up 7.4 percent in 2005, and gaining another 5.9 percent in 2006.

But not all physicians are prospering. The charts I ran last week show pediatricians, family doctors and others who practice what some call “cognitive medicine” (talking to and listening to the patient ) making as little as $115,000 a year while specialists who perform the most aggressive procedures haul home $800,000.

In your comments on the last post, some suggested that I was picking on
well-heeled specialists. “What about plumbers?” one reader asked. It’s
true that plumbers are well-paid. But I’m quite certain that none earn
$800,000. Of course they also didn’t go to school for 8 or 9 years to
learn their trade.

Let me suggest that, rather than comparing U.S. doctors to plumbers or
lawyers, it makes more sense to compare them to physicians in other
countries.  On that score, I found some provocative numbers in Robert Stowe England’s 2007 report, “Physician’s Role in Rising Health Care Costs: Perspectives on the High and Rising Cost of Physician Compensation.”

Stowe, a research fellow at Americans for Generational Equity,  points
out that primary care doctors and other “generalists in the United
States earn on average $173,000 a year or 4.2 times gross domestic
product (GDP) per capita. In other countries of the Organization for
Economic Cooperation and Development (OECD), generalists earn roughly
half as much – or $94,000 on average –based on purchase power parity
dollars.” Thus, Stowe puts the salaries in the context of what these
earnings can buy in each country.

Meanwhile, he continues, “specialists in the United States earn an
average of $274,000 a year or 6.5 times GDP per capita. In other OECD
countries, specialists earn on average less than half that at $129,000
or 4 times GDP per capita.”  So, Stowe concludes, “even adjusted for
higher wealth and earnings in the United States, the gap between what
physicians earn here and elsewhere in the developed world is large, as
is the gap between physician earnings and the average American’s
earnings.”  (Stowe recognizes that American doctors pay more for
malpractice insurance than their peers abroad, but in his comparisons,
this is already factored into the numbers.)

American doctors also do more, Stowe reports: “According to a
calculation by McKinsey Global Institute, based on OECD data, even
though the United States has fewer physicians per capita, U.S.
physicians have 8.9 consultations per capita, while in Europe the
number of consultations is lower, ranging from 3.4 in Switzerland to
7.8 in Belgium. Surveys of U.S. physicians confirm that productivity,
usually tied to the fee-for-service structure, is the largest factor in
compensation.”

In other words, the way we pay U.S. doctors motivates them to see more
patients and perform more procedures.  And they are doing just that.
Stowe reports that the volume of physician services “rose 5.5 percent
per beneficiary a year in 2004 and 2005. Per capita volume in imaging
is the leader in volume growth, increasing 10.3 percent annually
between 2000 and 2004 and 8.7 percent 2004 and 2005. There was a slower
3.8 percent growth per year for major procedures, including
cardiovascular procedures, knee replacement, hip fracture replacement
and others. Yet, given the cost of these procedures, this steady growth
is costly. The category known as ‘other procedures,’ which includes
minor procedures, such as radiation therapy or colonoscopy, among
others, rose 6.4 percent between 2004 and 2005, and 8.5 percent between
2000 and 2004.” And there is little evidence that this growth in volume
has led to higher-quality care. Indeed, there is much evidence that in
certain areas—particularly cardiac care—we have reached a point of
diminishing returns. We’re doing more, but patient outcomes are no
better. (See this 2006 article in Health Affairs).

Still the perverse financial incentives of our fee-for-service system
encourage “doing more.”  Indeed, a national study of 6,600 physicians
released in January 2007 by the Center for Studying Health System
Change reveals that 70.4 percent of physicians in group practice say
that “productivity” incentives are a factor in their compensation.  By
comparison, just 20.3 percent report quality incentives as a factor in
compensation.

As I’ve discussed before on this blog, paying physicians for the
quantity of work that they do rather than the quality leads to
overtreatment—which can be hazardous to your health. And Stowe notes
that even while physicians themselves are cranking up volume in order
to make up for the fact that fees-per- service are not rising, “a
growing number of physicians recognize publicly that productivity-based
incentives are working to raise costs, generate overutilization, and
unnecessarily drive up health care costs. They have called for reforms.”

At the same time, Stowe observes, American doctors feel a pressing need
to make more than their OECD counterparts in part because they stagger
out of med school carrying enormous loans.  In many other wealthy
countries the cost of medical school is subsidized by the government—a
practice which makes a great deal of sense, especially when you keep in
mind that in the U.S. the government (i.e. taxpayers) lay out roughly
50 percent of the $2.1 trillion that we spend on health care. Taxpayers
wind up paying U.S. doctors more because, when they graduate,  they
carry debt of $125,000 or  more—just at a time when many are hoping to
marry, buy a home, and begin starting a family. The young man or woman
who began med school as an altruist is now desperate to make as much
money as possible as quickly as possible.

Instead of putting young doctors under that kind of financial pressure,
why not subsidize their education, and then, when they graduate, pay
them salaries that fall somewhere between what we now shell out and
what OECD countries pay their doctors?  If the average specialist
emerged from med school debt-free he wouldn’t need to scramble to bring
home 6 percent of GDP. If specialists averaged, say, 5 or 5.5 times GDP
(adjusting for higher incomes in the U.S.) they still could consider
themselves well-paid compared doctors in Europe making 4 times GDP.
And they wouldn’t feel driven to see more patients than they can easily
handle, or do more and more procedures year after year. (This is just a
quick back-of-the-envelope proposal; in reality, we would no doubt want
to cut some specialist’s incomes by more, while hiking others. In an earlier post,
I discussed why the Medicare Payment Advisory Comission suggests we’re
overpaying for some procedures, underpaying for others.)

Meanwhile the nation could save billions—money that could be used
toward the medical school subsidies. For we wouldn’t just be saving the
amount pared from some specialists’ salaries, we would also be saving
the cost of the drugs they wouldn’t be prescribing, the devices they
wouldn’t be using, the tests they wouldn’t be ordering, and the
hospital beds they wouldn’t be filling as they saw fewer patients less
often.  As Alan Sager and Deborah Socolar point out in “Health Costs Absorb One-Quarter of Economic Growth, 2000-2005,” U.S. physicians receive or control 87 percent of all spending on personal health.

And I suspect that many doctors would be happy with the trade-off.   In
terms of quality of life, many would consider being debt-free when they
graduated in their early 30s more important than making 16 to 20
percent more when they were 57—especially if they didn’t have to rush
through their appointments in order to make their numbers.  Again,
doctors themselves are not happy to be laboring in a health care system
where they are rewarded for doing more rather than for taking better
care of their patients. Most physicians are as frustrated as their
patients by the hurried appointments and lack of real communication
between doctor and patient.

But wait a minute: if doctors see fewer patients and perform fewer
procedures, won’t patients suffer? All of the evidence says “no.” More
than two decades of research done by doctors at Dartmouth show that
outcomes are no better in parts of the country where patients see more
specialists and spend more time in hospital beds. In fact often these
outcomes (which are adjusted for differences in race, sex and overall
health of the population in different regions) are better when patients receive less intensive, less aggressive and less expensive care.

Moreover, in countries like Switzerland, where patients see physicians
less often, both outcomes and the over-all health of the population are
high when compared to the U.S. This is in part because, in these
countries, there is less emphasis on aggressive hi-tech care, and more
emphasis on low-cost, sometimes free, preventive care—before the
patient becomes deathly ill.

Yet, while many U.S. doctors are not happy with our profit-driven
fee-for-service system, others feel that in a society where they find
themselves surrounded by billionaires, they should be earning more.
Since the 1980s, levitating CEO salaries have increased the pressure on
doctors to take home a bigger paycheck. Wealth, after all, is always
relative, and as CEOs began to demand millions, doctors earning, say
$500,000 a year, began to feel unappreciated. “It’s a matter of
respect,” one doctor told me. “I’m smarter than he is; I have more
education, and I work harder. Why should he make more money?”

This helps explain why, in recent years, physicians have become more
entrepreneurial, investing in outpatient clinics and surgical centers.
Here, once again, what Stowe describes as “the perverse incentives of a
productivity-based fee-for-service business model” come into play as
doctors pad their income by referring patients to clinics and
free-standing surgical centers where they have an ownership stake. A
breakdown of physician earnings shows what a powerful earning stream
this can be.
“The McKinsey Global Institute calculates U.S. physicians earned $160
billion a year in 2003, segmented as follows: $45 billion in
fee-for-service income from hospitals with an additional $90 billion in
fee-for-service income from outpatient facilities. In addition,
physicians earned $25 billion from profits in physician-owned
facilities.”

Sometimes when doctors send patients to facilities where they have a 50
percent stake, they are sending patients for services that they don’t
entirely need. A study published in the Journal of the American Medical Association
in March takes a look at the rate of coronary by-pass operations in
local populations after a physician-owned cardiac hospital is built. It
turns out that once physicians opened the doors of their new facility,
the number of coronary artery bypass grafts (CABG) as well as
angioplasties suddenly shot up by 19.2 percent.  Was the population
suddenly sicker? We know that, in health care markets, supply creates
demand. (“Build the beds and they will come.”) But the research
suggests that it wasn’t just the presence of a new facility; when
physicians become owners of a surgical center, they are motivated to
send many more of their patients for surgery.  By contrast, in markets
when new cardiac programs open at general hospitals the number of new
procedures increased by only 6.5 percent.

Moreover, Stowe reports, “the Medicare Payment Commission has found
that physician-owned hospitals cherry-pick the most profitable patients
(usually younger and in better health) and focus on areas of medical
practice that offer higher profits.” As one doctor confided when I was
writing Money- Driven Medicine, “ I sit on the board of a surgical
center where the physicians regularly talk about sending some patients
to the community  hospital, and other, better-paying patients to our
surgical center.”

“This often leaves community hospitals with less profitable patients
and reduced opportunities to earn higher fees,” Stowe adds, and “in
turn, adds to the overall cost of the health care system, as community
hospitals scramble to offset lost business by charging higher fees in
other areas.

What can be done? In “Unhealthy Trends: The Future Of Physician Services,” a piece published in Health Affairs
just last month, the authors recommend “reexamining regulatory and
administrative rules within Medicare. In particular, expansions and
more-stringent enforcement of laws against physician self-referral, and
higher standards for the credentialing of providers, could help curb
services with the highest volume growth, such as diagnostic testing.”

Secondly, they argue, Medicare needs to restructure physician payment.
Congress is threatening to slice the average fee that Medicare pays
physicians by 10 percent this summer. But, the study notes “continued
use of such a blunt tool (whether applied as a single cap on all
physician services or as separate caps on individual categories of
services) would do little to discourage unnecessary services…”
Instead, the authors suggest, Medicare might consider paying primary
care physicians for services that they don’t reimburse for now—“such as
care co-ordination . . . while  revising fees to remove the inadvertent
incentives for specialists to favor certain high -priced
services”—something we talked about earlier this month.

But ultimately, the authors join the consensus that Medicare needs to
move away from a fee-for-service structure to a greater reliance on per
episode or capitated payments, while rewarding physicians for
efficiency and good outcomes. As we have discussed on this blog before,
high quality and lower cost go hand in hand. Health care providers that
achieve the best results also tend to use fewer resources.
Here, the study’s authors agree with other researchers that it is all
but impossible to pay either a solo practitioner or even a medium-sized
group of physicians for quality. Their patient pool is too small—which
means that a relatively small number of poorer, sicker patients can
skew their results. And we do not want to encourage physicians to shun
poor or difficult patients. Secondly, physicians usually have little
control over what happens to their patients when they are in the
hospital and outcomes can be undermined by poor hospital care.

As a result, the authors suggest that Medicare “offer premium payments
to doctors who work in, or are willing organize into, large
multidisciplinary groups that have stable relationships with a narrow
referral network of other providers (such as hospitals) whom the
doctors have selected on the basis of quality and cost performance.”
They point out that “these doctors/hospital groups would need to be
integrated in culture and by care processes and health IT, with the
expertise and ability to measure, report, and be held accountable for
the quality and cost of care…If physicians continue to exhibit the
rational responses to financial incentives evident in recent trends,
then under such circumstances, less well-organized physicians would
have a strong motivation to change their practice organization. “

Here I would add that by bundling payments to doctors together with the
hospital reimbursements, Medicare would be encouraging doctors and
hospitals to work together to assure that patients receive the best
possible care. Today, too often, doctors and hospitals compete. Often
they work at cross-purposes. By contrast, at a place like the Mayo
Clinic, everyone understands that 21st century medicine is a team sport.

Finally, do I think we pay doctors too much? No—but I think the
healthcare dollars that we pay for physician’s services need to be
redistributed. We should pay the generalists who provide preventive
care and practice cognitive medicine more. At the same time, we need to
cut the salaries of some specialists who focus on the most aggressive
care—especially in cases where it appears that they are talking
patients into unnecessary procedures. We might consider putting a cap
on how many operations they can do in a given year.  And, as I
mentioned, I also would favor taking some of the dollars that we now
pay for physician’s services and use it to subsidize medical education.
In total, we would be funneling the same amount of money to physicians,
but in very different ways.

Going forward, we cannot afford to watch spending on doctors’ services
jump 6 percent or 8 percent a year. Here, as in other areas of our
health care system, if we want sustainable high quality health care for
all, our outlays cannot continue to grow faster than per capita GDP.
Healthcare is an important part of the economy, but we cannot let it
swallow the economy.

30 thoughts on “Health Care Spending: The Basics; Spending on Physicians’ Services-Do We Spend Too Much? Part II

  1. It seems the policy types are again moving towards integrated delivery systems, but want to present it in a softer light given the pushback from providers (and failed efforts) the last time it was tried in the 90s.
    One interesting development along these lines was the announcement by BCBS MA today. They are looking to create almost exactly the financial incentives for integration and risk-acceptance that Maggie describes.
    see here: http://www.boston.com/business/healthcare/articles/2008/01/22/new_therapy_for_old_woes/?page=1

  2. jd
    thanks for sending the link. Yes, what Blue Cross Blue Shield in Mass plans to do is very similar to what I was describing.
    At this point people are reaching a consensus as to what’s needed to control costs while raising quality.
    As you say, the large multi-speciality group is back in favor. One reason it didn’t work in the psat is that many specialists at the top of the ladder objected to sharing revenues with family doctors and other specialists who were less well-paid.
    But i think in the future we are going to see Medicare leading the way in adressing some of those disparities in physician’s incomes. The differences won’t disappear but they won’t be so huge.
    And newly minted doctors tend to be much more intersted in joining large multi-specialty groups. They belong to a generation that learned to work in groups in grade school . . .

  3. That sounds right to me, though I’d add that I’m a little less optimistic that Medicare will lead the way. They’ve been making noises for reform over there, but we’ll see what kind of staying power they have.
    As for the popularity of larger groups, EMRs are also a factor. It’s easier to implement when you can have dedicated staff, and the payoff is larger as well.

  4. What BCBS MA wants to do is very sound conceptually, but it could be challenging to execute effectively. The key issues for the medical group are: (1) how will the revenue be divided among hospitals, doctors and other providers, and, for doctors, between specialists and PCP’s, (2) how well will the group be able to project its costs a year in advance, and (3) how good is the risk adjustment mechanism that is supposed to compensate for older, sicker, and poorer, difficult to treat patients who are likely to utilize more healthcare service?.
    If I were the insurer, I might try to set the aggregate payment per member to a group willing to embrace the fixed payment approach at the prior year utilization level + 100 basis points below the estimated increase in the medical cost trend that its products are priced to plus or minus a risk adjustment payment to reflect the relative health of the practice’s patient population plus a potential bonus of 25% of any savings between expected utilization based on the prior year experience plus the current year estimated medical cost trend and the actual utilization for the current year. For practices that stay in the old fee for service system, there would be no opportunity to earn a bonus, but good performers could earn a premium designation for cost-effective practice with members given an incentive to use them via a lower co-pay.

  5. Since I’m the author of the “plumbers” remark I think I should comment.
    If you are going to compare the income of doctors in the US to elsewhere then you need to do it in some normalized fashion. For example, what is the ratio of doctors to lawyers in the US compared to the UK or EU?
    Or doctors to plumbers, for that matter.
    The higher incomes of doctors only should be a concern if they are disproportionately higher compared to other professions. Even a straightforward comparison of the ratio may be misleading, because, as you say, US doctors have to pay back the cost of their education at a level that is not seen elsewhere. They also have higher overhead, in part due to the burdens of dealing with a fragmented insurance system.
    Look at CEO’s earnings. In the US the ratio to the average worker is about 435:1. Elsewhere it is more like 30-60:1. That’s an example of a market distortion.
    You haven’t proven your case against doctors (yet).

  6. Maggie,
    Your analysis of physician salaries once again leaves out the opportunity cost that U.S. physicians take on.
    While I agree that I’d take a lower salary if you would also throw in a European-length vacation package, hours, and tuition reimbursement, I would still argue that the opportunity cost of age 22-26 means there has to be greater financial compensation for those who choose that path. Until the US also adopt a undergraduate medical degree as well, no one will bite at this version.

  7. Maggie,
    As one of the lowly primary care docs toiling away daily in the medical mines, I have enjoyed your recent posts. One question: why do you believe Medicare will soon address the huge and growing income disparity between primary care physicians and specialists? It seems so obvious that this must be done if primary care is to survive, yet powerful interests will oppose any such efforts. Specialists have more money and are better organized, and the drug and device companies that profit from all the procedures will fight any changes. What do you think will actually lead to substantive change in the payments for physican services?
    As an aside, I want to give you an anecdote from today that supports what you say in this article. I received a consultation letter from a cardiologist I know well. I had not actually consulted him, but he called it a consult since he could bill higher for a consult than for an office visit when the patient self referred. Anyway, the patient was a 30 year old woman who fell and struck her rib cage against something about two weeks ago. She had chest pain, not surprisingly. What was surprising? The cardiologist ordered an echocardiogram and a stress test. This patient clearly had chest wall pain from the injury, but he couldn’t let her get out of the office with merely a $200 consultation fee. No, he needed to boost the old productivity with two egregiously unnecessary procedures.
    This sort of thing happens on a daily basis where I practice.

  8. A couple of points:
    I wonder if the reduced salary in exchange for subsidized tuition brings salary ranges down to the actual PPP-adjusted incomes from other countries. One way to find out would be to look at public health scholars who have a service payback in exchange for tuition assistance; or else the salaries of physicians benefiting from federal loan repayment programs (I suspect they are lower than the average US salary). I don’t know if anyone has ever looked at this systematically. Starfield’s group at Hopkins has routinely used the disparity between primary and specialist practitioners as an indicator in their comparisons of health systems.
    My second point is a word of caution; although I may agree with your brilliant analysis, I do not believe central planning and legislative approaches work. A well-thought-out market system should do a better job; but healthcare is a complex many-headed beast, so it is difficult for anyone to think through.

  9. I hate to keep flogging the same issue, but this from Wellpoint today:
    “The benefit expense ratio was 82.9 percent in the fourth quarter of 2007”
    I don’t care how you slice the numbers paying out 83% is 17% overhead in my book. This compares with the 97% from Medicare.
    When Blue Cross was non-profit (before it became Wellpoint) it also paid out in the 94-96% range.

  10. I love the conflicted reasoning in this blog.
    “More than two decades of research done by doctors at Dartmouth show that outcomes are no better in parts of the country where patients see more specialists and spend more time in hospital beds. In fact often these outcomes (which are adjusted for differences in race, sex and overall health of the population in different regions) are better when patients receive less intensive, less aggressive and less expensive care.”
    Take this to the absurd extreme and it implies NO medical care would result in the BEST outcome.
    Time to reveal a bit about myself. I live in Indiana, flyover country. A county near me (Carroll) has NO hospital, zip, zilch, nada. It has a couple of GPs and that’s it. NO paramedics, just volunteer EMTs.
    Reading the newspaper shows if you have a heart attack in that county (Carroll), you’re dead. Why is this? By the logic of “outcomes … are better when patients receive less intensive, less aggressive and less expensive care.” then these poor souls should be walking around in excellent health instead of being six feet under. FYI, it’s at least 30 minutes to the closest hospital, 45 minutes to the closest trauma center, 90 minutes to the closest Cardiac ICU.
    The second conflict is about reimbursement. Dr. Nugent relays the story about a patient who SELF-REFERRED to a cardiologist. It’s implied that the patient insisted on an ECG and stress test. Unless someone was robbed at gunpoint to pay for said procedures, who cares? People make choices for reasons we don’t understand. It is possible that heart disease runs in her family, and the rib injury was an excuse to get her heart checked out…. Would the collective have factored THAT into its reasoning?
    Finally, comparing the compensation of U.S. doctors to anywhere else is, at face value, worthless. The U.S. is the ONLY country where the government does not own and operate the medical system (If the government pays the bills, I consider that owned and operated (Golden Rule: Them that has the Gold, Makes the Rules)).
    In the U.S., a doctor’s compensation is, in part, a result of their own hustle. Everywhere else, it does not matter how much time or effort a doctor makes, the check remains the same. Apples and Oranges.
    The tortured logic employed on this blog to justify a government agency either funding or completely operating the medical care system in the U.S. while maintaining the illusion that the patient would have any say in such a system is hilarious.
    See http://www.covertrationingblog.com/
    for a take on rationing medical care that makes some sense.
    Sidebar: On many medical blogs, there is an almost maniacal obsession about eliminating “money” from medical care. Memo to Earth: Medical care is NOT a religion, repeat: Medical care is NOT a religion. Doctors do NOT take an oath of poverty nor are they required to don sackcloth and ashes.
    Medicine is one of the ancient professions, and compensation for services rendered is customary and expected.

  11. BobMan,
    I think you totally missed the point of my anecdote. I didn’t imply the patient insisted on anything; in fact, the patient was merely along for the ride. There is heart disease in her family, but 30 year old females do NOT need evaluation for clogged arteries if they have atypical chest pain, and EVERY doctor knows this. She wasn’t seeking anything other than an explanation for her pain. THAT’S the point. The cardiologist chose to order unnecessary, expensive tests to pad his income, rather than just tell her she was okay and send her on her way. That’s precisely what you get when you overpay for tests and procedures–you get more tests and procedures and more of the people who get wealthy doing the tests and procedures. And who was robbed? Well, no guns were involved, and the money came from the insurance company and the patient’s pocket in the form of deductibles and copays. These tests weren’t dangerous, but I see cardiologists order unnecessary cardiac catheterizations all the time, and those DO carry risk to the patient beyond the wasted money. I’ve seen barely conscious nursing home patients get four or five expensive drug eluting coronary stents, for one reason and one reason only: Medicare will pay (handsomely) for it. You flippantly dismiss what I think is a pretty serious ethical issue. We can’t as a country continue to promulgate a system that uses patients as money-generating substrates. Money corrupts, and it has corrupted a lot of doctors who see dollar signs when the patient walks in the door. I’m ashamed that it’s the case, but it is, and this MATTERS. You ask who cares? Well, what rational person would not care?

  12. BobMan;
    I am uncertain from your comments what your involvement in the healthcare system is (worker? patient? Doctor?) but I have to agree that you didn’t see the point about the 30 yr old with musculoskeletal chest pain. First, if she DID insist on those tests, fine; let her pay for them. Second, I can add numerous similar unnecessary care/tests anecdotes that have happened to my own family, including my 86 yr old mother who was disabled from muscle pain complications from Lipitor, prescribed DESPITE a normal cholesterol level. (Besides, at 86 the effect Lipitor would have would be negligible due to her limited life expectancy anyway). The big point you are missing is that all this extra care can cause HARM, and that is actually thought to be the cause of the higher mortality in areas of high concentrations of medical specialists. There is RISK to almost all medical treatment, despite what patients want to believe.
    As for the location where you live having no doctors, that’s because they’re all in the big cities where they can make more money. Wouldn’t you like to have better access to care from docs who don’t have big loans to pay off or big houses to mortgage and therefore aren’t always chasing the almighty dollar?

  13. While the cardiologist who administered the stress test and ECG to the 30 year old woman may have done it for financial reasons, it is also quite possible that he did it as part of a culture of defensive medicine, especially if he knew that heart disease ran in her family. While heart attacks are not common among the 30 and under population, they are not unheard of either. If the cardiologist is practicing in an especially litigious state or city, he may have feared a malpractice suit if he did not administer the stress test and the woman subsequently had a heart attack. As I understand it, many malpractice suits are based on a failure to diagnose and not a botched procedure, wrong drug, etc.
    The case of the stents being inserted into barely conscious elderly nursing home residents most likely was financially driven, especially since this is one of the procedures that Medicare pays especially well for. On the other hand, the doctor, nursing home and/or the hospital may also have feared a lawsuit if they didn’t do everything possible to keep the patient alive as long as possible. Obviously, we need sensible guidelines as to just what constitutes good, sound, medical practice, especially under these circumstances, and we need a tort system that will not allow a suit to be successful if sound, evidence based guidelines were followed.
    The magnitude of healthcare costs attributable to defensive medicine is, unfortunately, impossible to quantify with any precision. Progressives think it is a minimal factor contributing to rising healthcare costs. I’m not so sure. I think it is deeply embedded in the medical culture here. The fact that these tests and procedures also contribute to the income of the doctors who order and perform them only exacerbates the inclination to do them. This is why, in addition to tort reform, we need information on doctor driven healthcare utilization, especially among specialists.

  14. Marc, BevMD, BobMan, Robert, Zagreus, K, Barry-
    Thank you all for your comments.
    Mark–your story is an excellent illustration of what I’m talking about. And you’re right, it happens all the time.
    Why do I think Medicare is going to have to address the huge and growing disparity in physicians’ salaries?
    They don’t have much choice. The Medicare Trust Fund is going to run out of money fairly soon.
    Right now, the only “solution” on the table is to cut doctors’ salaries by an average of 10 percent across the board. (A very crude way to cut costs)
    Congress was supposed to do that at the end of 2007–then it chickened out. Congressmen know that, if they do this, many doctors–especially poorly paid primary care docs–will stop taking new Medicare patients .
    Moreover, the 10% cut wouldn’t be enough to save Medicare’s budget. Current law says that Congress would have to do another across-the-board cut in fees Medicare pays docs averaging 15 percent (for a total of 25 percent) in the next year or so.
    Imagine how many docs would simply refuse to take Medicare patients. Middle-aged doctors who could afford to might well retire.
    Imagine the outcry from the AARP and seniors everywhere. Seniors vote.
    So Congressmen know that they have to find another way to save money. MedPac (the Medicare Payment Advisory Comission) has told them they should address the disparities in doctors’ salaries by revising hte fee schedule–and having disinterested parties look at specialists fees.
    I don’t see what else Congress can do.
    And once Medicare adusts its schedule, private insurers will follow. Even unenlightened private insurers understand that you can keep patients healthier at a lower cost if they see more primary care docs who do preventive care rather than waiting until they are really sick to see a specialist. But those primary care docs have to have the time to manage their care. They can’t be seeing a patient every 10 minutes. They must be paid more so that they can slow down.
    Finally, we’re facing a real shortage of primary care docs. In Manhattan it’s getting very hard to find someone good who takes insurance of any kind and is taking new patients. I’m told the same is true in Boston. Too
    many specialists, not enough family physicians.
    Yu’re right: the lobbyists for drugmakers and devicemakers as well as some (but not all) specialists and surgeons will fight this. But legislators will be caught between a rock (angry seniors) and a hard place (angry lobbyists.)
    If the seniors are angry enough, the lobbyists campaign contributions won’t matter; they’ll lose their seats anyway.
    Angry seniors do have a history of getting their way. Unlike many other voters, they have the time and the interest to focus on issues.
    Bev M.D. —
    Thanks you and Mark for addressing BobMan’s questions. I couldnt’ have said it better.
    And your story about your mother and Lipitor is one I’ve heard many times before. I’m certain that Lipitor is over-prescribed– especially for older people who often suffer muscle pain as a result (and may well be dying of somehing else so the threat of heart disease is not a big worry).
    You’ll find Niko’s new post (today– Friday) interesting. (See second half).
    IF any doctors out there have any information about the link between cholesterol and heart disease and whether it is overblow, I’d be very interested.
    BobMan — I really don’t have anything to add to Mark and Bev MD’s responses to your post.
    K– If a med student is concerned about being paid every penny that he might be paid for the “opportunity cost”, of lost opportunities while training to be a doctor–then maybe he shouldn’t become a doctor.
    I mean that sincerely. For many physicians the opportunity to do such useful, valuable and potentially interesting work is something they value. They don’t need to be paid for giving up those years studying medicine–rather than, say, studying investment banking.
    People really shouldn’t go into medicine for the money. There are many, many much easier ways to make the same money–or more.
    Zagreus– if the market was going to work to improve our health care system, it would have done so a long time ago.
    There is a reason why we are the only country in the world trying to make a “market solution” work. Meanwhile we spend twice as much as the average developed country and our outcomes are significantly worse.
    I heard Don Berwick, head of the Institute of Healthcare Improvement, talk about this today–and I also interviewed him before he spoke.
    . He’s brilliant on the subject and I’ll be posting on what he has to say.
    Robert– I’m not trying to make a case against doctors.
    I don’t care whether doctors make more or less than lawyers. What I do care about is that too many doctors purposefully jack up their volume in order to increase their incomes–and this Harms Patients.
    It isn’t just a
    waste of money. It is hazardous to our health. See Bev M.D.’s post.
    In additon it wastes health care dollars that could be used to make sure that six-year-olds receive preventive care.
    On Wellpoint– one other factor affecting overhead these days is the fact that private insuers are spending huge amounts advertising and marketing their Medicare advantage plans.
    Once they have customers locked in (seniors find the whole process of picking a plan so bewildering that most won’t change even if unhappy) insurers expect to more than make up for the costs. But right now, they’re happy to spend to reel them in and enroll them.

  15. Marc, BevMD, BobMan, Robert, Zagreus, K, Barry-
    Thank you all for your comments.
    Mark–your story is an excellent illustration of what I’m talking about. And you’re right, it happens all the time.
    Why do I think Medicare is going to have to address the huge and growing disparity in physicians’ salaries?
    They don’t have much choice. The Medicare Trust Fund is going to run out of money fairly soon.
    Right now, the only “solution” on the table is to cut doctors’ salaries by an average of 10 percent across the board. (A very crude way to cut costs)
    Congress was supposed to do that at the end of 2007–then it chickened out. Congressmen know that, if they do this, many doctors–especially poorly paid primary care docs–will stop taking new Medicare patients .
    Moreover, the 10% cut wouldn’t be enough to save Medicare’s budget. Current law says that Congress would have to do another across-the-board cut in fees Medicare pays docs averaging 15 percent (for a total of 25 percent) in the next year or so.
    Imagine how many docs would simply refuse to take Medicare patients. Middle-aged doctors who could afford to might well retire.
    Imagine the outcry from the AARP and seniors everywhere. Seniors vote.
    So Congressmen know that they have to find another way to save money. MedPac (the Medicare Payment Advisory Comission) has told them they should address the disparities in doctors’ salaries by revising hte fee schedule–and having disinterested parties look at specialists fees.
    I don’t see what else Congress can do.
    And once Medicare adusts its schedule, private insurers will follow. Even unenlightened private insurers understand that you can keep patients healthier at a lower cost if they see more primary care docs who do preventive care rather than waiting until they are really sick to see a specialist. But those primary care docs have to have the time to manage their care. They can’t be seeing a patient every 10 minutes. They must be paid more so that they can slow down.
    Finally, we’re facing a real shortage of primary care docs. In Manhattan it’s getting very hard to find someone good who takes insurance of any kind and is taking new patients. I’m told the same is true in Boston. Too
    many specialists, not enough family physicians.
    Yu’re right: the lobbyists for drugmakers and devicemakers as well as some (but not all) specialists and surgeons will fight this. But legislators will be caught between a rock (angry seniors) and a hard place (angry lobbyists.)
    If the seniors are angry enough, the lobbyists campaign contributions won’t matter; they’ll lose their seats anyway.
    Angry seniors do have a history of getting their way. Unlike many other voters, they have the time and the interest to focus on issues.
    Bev M.D. —
    Thanks you and Mark for addressing BobMan’s questions. I couldnt’ have said it better.
    And your story about your mother and Lipitor is one I’ve heard many times before. I’m certain that Lipitor is over-prescribed– especially for older people who often suffer muscle pain as a result (and may well be dying of somehing else so the threat of heart disease is not a big worry).
    You’ll find Niko’s new post (today– Friday) interesting. (See second half).
    IF any doctors out there have any information about the link between cholesterol and heart disease and whether it is overblow, I’d be very interested.
    BobMan — I really don’t have anything to add to Mark and Bev MD’s responses to your post.
    K– If a med student is concerned about being paid every penny that he might be paid for the “opportunity cost”, of lost opportunities while training to be a doctor–then maybe he shouldn’t become a doctor.
    I mean that sincerely. For many physicians the opportunity to do such useful, valuable and potentially interesting work is something they value. They don’t need to be paid for giving up those years studying medicine–rather than, say, studying investment banking.
    People really shouldn’t go into medicine for the money. There are many, many much easier ways to make the same money–or more.
    Zagreus– if the market was going to work to improve our health care system, it would have done so a long time ago.
    There is a reason why we are the only country in the world trying to make a “market solution” work. Meanwhile we spend twice as much as the average developed country and our outcomes are significantly worse.
    I heard Don Berwick, head of the Institute of Healthcare Improvement, talk about this today–and I also interviewed him before he spoke.
    . He’s brilliant on the subject and I’ll be posting on what he has to say.
    Robert– I’m not trying to make a case against doctors.
    I don’t care whether doctors make more or less than lawyers. What I do care about is that too many doctors purposefully jack up their volume in order to increase their incomes–and this Harms Patients.
    It isn’t just a
    waste of money. It is hazardous to our health. See Bev M.D.’s post.
    In additon it wastes health care dollars that could be used to make sure that six-year-olds receive preventive care.
    On Wellpoint– one other factor affecting overhead these days is the fact that private insuers are spending huge amounts advertising and marketing their Medicare advantage plans.
    Once they have customers locked in (seniors find the whole process of picking a plan so bewildering that most won’t change even if unhappy) insurers expect to more than make up for the costs. But right now, they’re happy to spend to reel them in and enroll them.

  16. Thank you Barry for reminding us of the hidden cost of defensive medicine. Although I think anecdotes have less persuasive utility in discussions such as these, pardon me for adding two more to this thread.
    #1)I know of a dermatologist in an academic practice (on a salary, not fee for service) who essentially biopsies almost all “moles” that her patients have questions about, even the clinically benign ones. Why? Because she fears that she might otherwise miss diagnosing a melanoma. Her concerns are genuine, as if she goes by clinical judgment alone and doesn’t biopsy the benign appearing moles, and is in practice long enough, someday she will likely miss diagnosing a melanoma that was masquerading as a benign mole. Delay in diagnosing a melanoma is a major cause of malpractice suits filed against dermatologists. The additional cost of biopsying a mole and the pathology fee to examine the specimen can add up to over $300. I am sure other specialists have similar anecdotes of CYA measures to ward off potential malpractice charges.
    If we as a society want to lower the costs of medical care, we need to accept the fact that cost effective medicine (e.g. biopsying the clinically worrisome but not benign appearing moles) doesn’t equate with perfect outcomes (e.g. biopsying every mole that walks through the door).
    We need a medical-legal environment that will allow physicians to practice sound, cost effective medicine without the daily threat of costly litigation. I firmly believe that the vast majority of physicians are not milking the system for profit, and that the majority of unnecessary medical expenses comes from CYA maneuvers.
    #2)It has been estimated that John Edwards , who soon should be exiting from his presidential bid, made approximately 20 to 30 million dollars during his brief stint as a medial malpractice attorney. These are real dollars that came out of our health care system that would be better spent on helping people with their health care needs. I don’t begrudge someone for making a decent living, but when our legal system allows someone to become a multimillionaire in such a short period of time with our valuable and limited health care dollars, well it seems a bit obscene.
    Unfortunately we are dependent on or elected officials to pass tort reform legislation, but most of them are lawyers and no doubt have allegiances with their malpractice attorney brethren. As our health care system continues to unravel, perhaps then our elected officials will see the need for major tort reform.

  17. for non cardiologists, seeing patients under 30 with cad is ridiculously rare. for cardiologists, it is unusual. but in my clinic today, i saw 3 patients under 30 with cad. note this is exceedingly unusual, but certainly enough to make me think about it when evaluating patients. maybe they obtained a different history than the one you did. who knows?

  18. To anonmyous:
    I find it interesting that everyone wants to defend the cardiologist who ordered unnecessary tests on the 30 year old female. OK…. It’s not COMPLETELY impossible she has CAD, but come on. She fell and injured her ribs and has pain with inspiration. What could possibly make you think that is ischemia? When you couple a pretest probability of <1% with very atypical cardiac symptoms, AND you have an obvious, clear cut non-cardiac explanation for the pain, then you should NOT do an ischemia workup. He didn't do it as CYA, because there is no liability for NOT ordering tests another prudent physician in the community would not have ordered. I actually try to be as charitable as I can in my judgment of what other doctors do, but there's simply no excuse in this case. And no, he didn't get a different history than I did; it was the same.

  19. Mark, I hope I am not included in your “everyone” statement. If your facts are correct, and no significant details are missing, then I too would be suspect of the cardiologist’s actions. My point was that I think very few physicians order tests simply for personal monetary gain. I believe that most unnecessary testing is performed by US physicians for fear of potential malpractice litigation. I get very upset when I hear about instances, such as yours. In my career I have seen a few of my snowbird patients who have had a small basal cell skin cancer treated in Florida by Mohs’ chemosurgery, a more precise and expensive method compared to routine excisional surgery. The result is a $150 simple excision fee can become a $1000 Mohs’ procedure fee. The few times I have seen this, I have been outraged, as my nurses can attest. This might be a partial explanation why it costs so much more to care for the average Medicare patient in Florida, as it does in states such as Minnesota and Vermont. (Who knows if Medicare is even addressing this well publicized discrepancy?)
    So what can we do about the over utilization of our limited healthcare resources?
    1) As I mentioned in my earlier post, tort reform would undoubtedly be beneficial.
    2) What about the rogue physicians out there who are milking the system for personal financial gain? Perhaps we need a 1-800-HOT-LINE phone number where we physicians (and perhaps patients) can report suspected abuses. There would obviously need to be an agency (preferably a federal agency rather than the state medical board) with adequate resources to investigate these cases. Physicians should be periodically reminded of the phone number and agency’s existence. Rules on how to reprimand rogue physicians would need to be established. A website could be created where the general public and health insurers could review any past actions taken on physicians. The mere existence of such an agency might make a physician think twice about engaging in self-serving activities.
    3) Additionally, if patients shared more of the costs of their healthcare they might question the cardiologist about the need for additional testing, or might ask the dermatologist if there is a less expensive way of treating their basal cell cancer than Mohs chemosurgery. Similarly they might be more inclined to ask for a lower cost generic medication, question the need for the expensive MRI scan, or request an advanced directive to avoid end-of-life heroic measures. With the advent of generous health insurance/Medicare benefits, our citizens have become much too insulated from the cost of treatment. This insulation has facilitated the over utilization of health care services and the inflation of our nation’s health care costs.
    I think physicians would be more likely to concede some of their income if these and other issues were first addressed. Curing the over utilization problem by slashing physician fees, as Medicare is proposing, is misguided (though probably easiest to do) and will inevitably lead to physicians divorcing themselves from the whole insurance scheme. That may not necessarily be a bad thing, as it will likely expedite changes that are so desperately needed.

  20. Dan, anonymous and Mark–
    Thanks for your comments.
    Dan– Unfortunately, studies show that when patients have higher co-pays, they are just as likely to forego necessary treatment as they are to skip unncessary treatment.
    The result: down the road, they become sicker, and we all pay for their care (through higher insurance premiums or through Medicare)
    The research shows that in countries where there is no co-pay or deductible for preventive care patients are much more likely to get the preventive care they need–and this is why they are generally healthier than we are.
    Everyone-I agree that relatively few physicians consciously overtreat in order to make a profit. There are a mix of reasons for “doing more” which include a fear of malpractice, a fear of hurting the patient by overlooking something, and the knowledge that, since your fees remain flat while your costs rise, you must increase volume to make your overhead (assuming you are paid fee-for-service).
    But probably the biggest factor behind over-utilization is supply. In areas where there are more hospital beds and more specialists, very similiar Medicare patients get twice as much treatment. (The comparisons adjust for differences in age, race and the overall health of the population.)
    We’ve long known how supply drives demand in the health care market: build the beds and they will come. And we now have three decades of research showing how Medicare spending on simliar patients doubles in areas where there are more beds and more specialists–yet outcomes are no better. Sometimes they are worse. (overtreatment can be hazardous to your health).
    This isn’t to say that specailists in these areas are consciously over-treating their patients. It’s just that in a town where there are twice as many cardiologists, those cardiologists are likely to see their patients twice as often simply because they have more room in their appointment book.
    After all, there is no “best practice” standard as to how often a doctor should see a patient suffering from congestive heart failures–every 2 months? every 3 months? every 6 months?
    If he has room in his appt. book he’ll see her more often. And if he’s practicing in a town where there are usually hospital beds available, he’ll be more likely to hospitalize her. And once she’s in a hospital, other specialists are likely to be be asked to consult on the case.
    Thus, in towns like Lubbock, Texas or Hattiesburg Mississipi, –where there are twice as many hospital beds per 1,000 patients as om some other cities, patients are far more likely to land in an ICU, seeing 10 or more specialists during the final six months of life.
    Fear of malpractice also can be a factor, but proponents of tort reform claim that state-wide caps on awards woudl reduce hospital spending –not enough to explain two-fold differences in the cost of care. MOreover, when reserachers drill down and look at academic medical centers treat patients in the same state, they find enormous differences based on number of beds and specailists.
    I’ve written about the reserach showing how supply drives demand here:
    http://dartmed.dartmouth.edu/spring07/html/atlas.php

  21. Dan, anonymous and Mark–
    Thanks for your comments.
    Dan– Unfortunately, studies show that when patients have higher co-pays, they are just as likely to forego necessary treatment as they are to skip unncessary treatment.
    The result: down the road, they become sicker, and we all pay for their care (through higher insurance premiums or through Medicare)
    The research shows that in countries where there is no co-pay or deductible for preventive care patients are much more likely to get the preventive care they need–and this is why they are generally healthier than we are.
    Everyone-I agree that relatively few physicians consciously overtreat in order to make a profit. There are a mix of reasons for “doing more” which include a fear of malpractice, a fear of hurting the patient by overlooking something, and the knowledge that, since your fees remain flat while your costs rise, you must increase volume to make your overhead (assuming you are paid fee-for-service).
    But probably the biggest factor behind over-utilization is supply. In areas where there are more hospital beds and more specialists, very similiar Medicare patients get twice as much treatment. (The comparisons adjust for differences in age, race and the overall health of the population.)
    We’ve long known how supply drives demand in the health care market: build the beds and they will come. And we now have three decades of research showing how Medicare spending on simliar patients doubles in areas where there are more beds and more specialists–yet outcomes are no better. Sometimes they are worse. (overtreatment can be hazardous to your health).
    This isn’t to say that specailists in these areas are consciously over-treating their patients. It’s just that in a town where there are twice as many cardiologists, those cardiologists are likely to see their patients twice as often simply because they have more room in their appointment book.
    After all, there is no “best practice” standard as to how often a doctor should see a patient suffering from congestive heart failures–every 2 months? every 3 months? every 6 months?
    If he has room in his appt. book he’ll see her more often. And if he’s practicing in a town where there are usually hospital beds available, he’ll be more likely to hospitalize her. And once she’s in a hospital, other specialists are likely to be be asked to consult on the case.
    Thus, in towns like Lubbock, Texas or Hattiesburg Mississipi, –where there are twice as many hospital beds per 1,000 patients as om some other cities, patients are far more likely to land in an ICU, seeing 10 or more specialists during the final six months of life.
    Fear of malpractice also can be a factor, but proponents of tort reform claim that state-wide caps on awards woudl reduce hospital spending –not enough to explain two-fold differences in the cost of care. MOreover, when reserachers drill down and look at academic medical centers treat patients in the same state, they find enormous differences based on number of beds and specailists.
    I’ve written about the reserach showing how supply drives demand here:
    http://dartmed.dartmouth.edu/spring07/html/atlas.php

  22. Maggie,
    I’ve many times heard the suggestion that when fees go down, doctors simply “do more” to maintain their level of income. The supporting evidence for this is largely that Medicare’s spending on physician services has been increasing well beyond that allowed under the SGR. This seems to have been driven by two factors: the number of beneficiaries is growing, and the volume of services provided per medicare beneficiary also has increased. Yet I have to suspect that the rise is fueled to a large degree by the advancing age of the average medicare beneficiary, and the technological advances in the services we are able to provide. In short — our patients are now older and sicker, so they need more care, and we are capable of doing more, so we do: more procedures, longer lives, more ICU days, etc. Certainly my suburban ER is a geriatric clinic these days, with some shifts where the youngest patient I see is 75.
    While I agree that the “if you build it, they will come” syndrome is at least a partial driver of costs, I wonder whether the greater demographic trends are more responsible for the growth in part B expenses. Thoughts?

  23. Shadowfax–
    I’m glad to hear from you.
    While many people talk about the aging of the boomers raising health care costs, the truth is that the boomers aren’t yet old enough to do that. (I know, I’m a boomer)
    The very oldest boomers are 62 or 63–not yet on Medicare.
    The vast majority (the bulge in the middle of the boomer bump) are in their
    late 40s to middle or late 50s.
    And, as a generation, boomers are healthier than previous generations. So, in their late 40s and 50s, they are, by and large, doing pretty well.
    They will add to the cost of Medicare once the majority of them are on Medicare–but that won’t happen for another 15 or 20 years.
    Today’s Medicare patients are getting more treatment not so much becuase there are more of them (the pre-boomer chort was pretty small becuase so many American men were gone–off fighting World WAr II), but because doctors are “doing more to them”– more than every before.
    This is in part because we can do more. We have so many new drugs and procedures. But it’s also because all of the incentives in our fee-for-service system push doctors to do more.

  24. Remember that in countries with lower physician reimbursements, the selectivity of physicians suffers. Also,having first hand experience Practicing in the Australian two-tiered system, I can tell you that the difference in care between the public and private systems in stark.How doyou think Americans will like a 24 month wait list for a specialist appointment? I have seen this first hand. Socialized medicine controls costs by care rationing.Here in the US, I have worked in poor,inner city hospitals, and see that most of the “uninsured” have not bothered to fillout medicaid applications. I am not saying that we have no problems in our system, but comparing us to low population, homogenous, healthy countries like Sweden is ridiculous. Most of the money spent on healthcare in the us is spent on self induced pathology (obesity, drugs leading to infant death, heart disease). The propaganda machine that tells the US population that the third leading cause of death is medical errors is intentionally dishonest. We can certainly curtail some costs, and I think that there is some abuse, but, as a young physician, all I see is decreased autonomy, decreased pay, increased workload, increased exposure to lawsuits. Most of my young Dr. friends will not advise their children to go into medicine, myself included
    Americans want Cadillac healthcare, and they want it free. Unfortunately it does not work that way . Your own data says physician pay has gone from 19 to 22 %. What has administrator pay done. How about the entire government bureacracy dedicated to regulating medicine. And you want to cut specialist pay? Specialists especially surgeons do the work that takes the most training and has the most severe consequences for mistakes. Also the highest impact on health for successes.
    Even surgeons are now just better than middle class, and not rich. This is ok, but cut 30% off the pay and the older experienced surgeons will retire en masse. Young , talented minds will begin to look at other fields with less stress and better pay.
    For me, for now I wouldn’t trade what I do for anything. But each year the negatives grow and the positives shrink. I just hope I can get 20 years of practice in before the bureacracy, pay decreases (yes doctors make SIGNIFICANTLY less money today than 10 years ago inflation adjusted), stress, underappreciation and negative propaganda finally sink the profession totally.

  25. You do realize that specialists (let’s say a neurosurgeon for example) compared to a primary care doctor should make more, right? This is not a knock to PC docs, but lets start from day 1 of medical school (which by the way comes after at least 4 years of undergrad) 99% of the time the specialist during medical school worked extremely hard and pushed and pushed, less time to see friends and family, less outside life, etc. You do then realize how hard they had to work on the boards (compare ex a 190 to a 240). You also then realize that a Primary care residency is 2-3 years after medical school (which is still a lot of work, don’t get me wrong) but the neurosurgeon has 7-8 years after medical school, 80-100 hour weeks working below minimum wage. You do then realize that after that what is at stake when you have to operate on the nervous system as opposed to a well visit? And then you do realize the difference in malpractice?
    I respect all fellow physicians, but I am so sick of the public and politics allowed to spout out whatever they want and then some are too affraid to just state the truth!!! I know a few mentioned some truths that I am sure the american public would love to hear (ie: they cause most of their own health care problems with obesity, ciggies, etc). Another final thought, until I can walk out of every hospital without people lighting up ciggies at the front door (very selfishly I might add) I refuse to pay for anyone elses healthcare without a fight.

  26. Let me see. I am 36 and in practice in EM for three years with 183,000 in student loans. An MBA is two more years of college. With my stellar ability at college (3.91 gpa) and test taking 253 and 243 on USMLE a top bussiness school and six figure starting salary would not be very hard to achieve. Good by medicine, let someone else deal with this sorry system, that does not want to pay for quality.

  27. What percentage of both private and public health care spending is spent on health insurance?
    What percentage of both private and public health care spending is spent on health insurance provided by small business employers?

  28. 8-9 years of training? Sure, for a primary care doc. The docs you’re talking about doing aggressive procedures and pulling in $800k/year are outliers in their fields, and they almost certainly in surgical specialties that required 4+ years of college, 4 years of med school, 4-6 years of residency (@ 80+ hours a week at barely minimum wage), and likely a year or two for a fellowship after (@ barely higher wages). Then they’d start around 200k/year, trying to make a dent in several hundred thousand dollars in loans (a grimmer reality each year as tuitions skyrocket and interest is no longer subsidized through schooling). The payments they make on these huge loans aren’t tax-deductible because they make “too much”, and reimbursements fall each year. They’re beginning a career in their 30s with no retirement savings/savings for kids, but they can hardly even think about that sort of thing working 60+ hrs/week and (if in a hospital) still taking call at night—all while trying to protect themselves against the constant threat of a lawsuit and invalidating all this work. The money is NO reason to become a doctor; in fact, those in search of money can find infinitely easier routes to it elsewhere.

    • aid-

      Yes the docs earning $800,000 are specialists. They train for more years and pile up more debt.

      Though under the Affordable Care Act, medical students will be able to get scholarships if they
      agree that, after they finish training, they will work in a part of the country where they are needed.
      In most specialties, we have enough doctors, but they are poorly distributed. They all want to live and work in the
      same places- cities on the East and West Coasts as well as inviting cities in other parts of the country.
      Most do not want to work in inner city Detroit or very poor rural areas.

      Under the ACA the program to provide funding for Doctors “Who Will Go Where No One Else Will Go” has
      been greatly expanded.

      As I have written in the past, I would favor subsidizing medical education for all med students– while
      reducing how much we expect to pay them.

      If a med student finished his training in his early 30s with NO DEBT,
      he could start a family, begin to save for his kids’ education and for retirement, and be free of the stress that
      comes with debt. If , when he began his career as a specialist, he earned,say, $250,000 and expected to earn
      $450,000 (rather than $800,000) at mid career wouldn’t that be preferable to starting out with so much debt?

      (I’m just throwing those numbers out as examples.)

      I agree that those who become doctors for the money are very foolish. There are much easier ways to make $600,000 $800,000 a year– in finance, real estate, banking, corporate America. And people who go into medicine for the money are usually pretty unhappy.