The physicians who are doing well are either the ones who don’t take or limit the amount of MEdicare/medicaid, or the ones who perform a lot of procedures. Medicare does pay decently for some procedures.

And yet new hospitals are constantly being built, physicians are opening new practices, and physicians have the highest average net income of any profession in the world. For all this claimed lack of profitability, there are still a lot of physicians living quite high on the hog.

“but the $75k to $100k that it takes to defend a case, and the few rather large awards that do go to paients, have driven many physicians out of practice “

That’s what it costs to take the occasional high damages case to trial, that’s not an average of all claims. And given that the bulk of large awards are for past or future medical bills, ie money that goes back into the system, that doesn’t really support your claim. And I don’t know what number is “many”, but it must be pretty low because I bet you can’t name even 10 physicians who have ever paid a claim out of their pockets.

You are right that there are lots of anecdotes, but very few facts.

At it’s root, our healthcare crisis is not declining physican income (although, declining physician income is a major issue). The 40+ million uninsured, the underinsured patients, the fact that we have almost no medical students going into primary care, and the unreal amount of money we spend on healthcare without any benefit over other countries is the healthcare crisis. I’m doubtful that better physician marketing is going to fix our crisis.

As for physicians choosing to be paid this way decades ago – and I assume you mean physicians chose Medicaid and Medicare – you or somebody else please fill me in on that bit o’ history. Furthermore, if you’re implying that Medicaid and Medicare remain profitable for physicians (or hospitals, or physical therapists, e.t.c.), I’d have to respectfully disagree with you. I don’t think you’d have to read very far into the medical blogs to find healthcare providers outlining how unprofitable these government programs are.

I agree that most court cases are won by physicians, but the $75k to $100k that it takes to defend a case, and the few rather large awards that do go to paients, have driven many physicians out of practice (and kept many out of certain states). The end result is that physicians and hospitals practice “defensive” medicine/care and end up spending a lot of uncessary healthcare dollars in order to try and avoid being sued – especially in emergency centers.

Not all Americans feel entitled to healthcare, but there are enough of them that do, and they are the ones that eat up a large part of our healthcare dollars – i.e. superusers, futile care, e.t.c.

Our society doesn’t have a sense of entitlement with this issue. Physicians chose this as a way to be paid decades ago. For years it was very profitable, and for the most part still is, but as with all things govt, it’s become a bureacratic pain in the ass. The problem is not society, it’s the way physicians market themselves and allow themselves to be paid. When enough of them are ready to get out and market themselves, to explain why physician A is better than physician B, and why we should be paid more for the services provided by A, then the market will turn. Until then, the only thing differentiating one from another in the public’s eye is whether they take my payment plan and when is the first appointment available.

As for the legal system “laying waste” to them, what a bunch of nonsense. Their insurers may be giving them a screwing, but physicins win nearly every time they go to court in this legal system.

As long as our society has a strong sense of entitlement, and as long as the legal framework of our society allows patients to lay waste to physicians, our healthcare system will remain broken.

The solution to our healthcare crisis largely depends on somebody being able to convince our society that healthcare is a need, not a right, and that certain rights might have to be sacrificed in order for the healthcare need to be met.

I think Hospitalist Refugee is correct that it’s not the black and white situations that suck up most of the resources–it’s the vast grey area in between, the enormous outlays for trivial gains. But what I read Ms. Mahar as suggesting is to reform now what we can reform–we should get started on the process. For example, fix at least the problem of paying for what we know now to be pointless, even if that is not the whole problem. We can go at this incrementally, fixing obvious things and seeing where that gets us. I think we can figure out a way to pay primary care physicians more and make them the principal deciders of what advanced care is appropriate by putting the weight of a reformed Medicare system behind their decisions. I suppose that would be a kind of rationing, but I think the elderly would accept it.

One other thing. I think those who attack Ms. Mahar personally should tell her who they are. After all, she says who she is.

I don’t doubt that the Medicare system is going bankrupt, but I don’t agree that limiting access to expensive procedures and therapies would solve the problem.

Here’s a real-life example of hospital charges and insurance limitation:

Recently my mother went to the ER with chest pains, trouble breathing, etc. After testing and some treatment in the ER, she was admitted overnight and underwent much more testing the following day. She was released that evening, just 19 hours after arriving at the ER.

She received the EOB (note she is not retired, not on medicare, and has a BCBS policy) and the hospital’s submitted charges were $8000. But the insurance plans ‘allowed charge’ was only $400.

She and I are some of the rare people, I guess, who are aware of original medical charges, insurance amounts, etc. She immediately thought, “this can’t be right. The room alone had to cost more than $400.”

So if Medicare is not paying a fair amount for care, insurance has demanded below-cost reimbursement, and uninsured aren’t paying their billed costs, then where is all the money going in the accelerating costs of healthcare?

(btw, I stopped really Happy awhile ago because he was causing higher blood pressure. As a patient with MS and RA and insurance which doesn’t pay for meds, I don’t see how his theories would help my situation and struggles.)

I came here by way of Dr. Wes.

1. We can do more than we did twenty years ago to treat disease more effectively, and that costs more money than letting the patient go untreated or providing the old quality of care (which can’t be ethically justified, if the new care is substantially better, in most cases). If a modern vent is better than 20-year-old tech, but costs more, what do you provide to patients?

2. Legislation binds physicians and health business into uneconomic standards of care to particular populations, specifically because, in a free market, those folks won’t supply that care otherwise. This is not intrinsically a bad thing, but needs to be financially backed up in the long run, by someone (usually other insured patients, these days).

3. Sooner or later, every patient wants the best care for themselves… It is their life, after all, and that’s pretty important to them. Not unreasonably. Eventually, someone will sue a healthcare provider for (1), regardless of their need and potential to pay.

Legislation will often make the outcome of (3) binding, and then all patients are required to be provided with maximal care, removing all autonomy. Withdrawl of care, rationing or even physician judgement are ultimately sacrificed, and the cost of care always increases. Legislation and litigation tie the hands of healthcare businesses, and that prevents the emergence of a balanced, competitive marketplace. Neither will relax their control until a crisis is sufficiently large that legislators have no choice but to allow some freedom, in order to prevent a system collapse.

The only way that this situation can improve, is if next-generation care is cheaper, while being more effective. Will we reach a point where this is true? Maybe, but maybe not.

Fortunately, many of the increases in cost of care over the past ten years are non-repeatable, such as organisational changes, infection care, HIPAA compliance, EMTALA demands, and so on.

No doubt, costs will rise, but we are presuming too much to expect that growth will be consistent with the previous decade, especially in light of the reduced output from the pharm industry leading to more prescriptions being for generics year on year, as patents expire.

Other advances, of course, will be expensive. To achieve long-term savings and improve care, EMRs will become more pervasive, needing large capital investment for systems and training, and the first few generations will suck until standards fall out, but over time, it will help. Walmart thrived, while K-Mart died, because of increased computerisation and automation, but the up-front cost was daunting. Healthcare provision is going to face some really big humps like that, and they will eventually be legislated, and there will be no choice in the end.

In other words, it’s going to suck for a while yet, even in the case of a non-collapse of the system.

On the upside, perhaps cost considerations will encourage providers to fund more palliative care programmes, for the profit motive, and perhaps more of our elderly patients and their families will be well-informed enough to enable them to pass on with the dignity that they are often seeking so badly.

I think that some docs understand the solution but certainly not all.

I just think it’s important to not blame specialists for this, primary care has to take some of the blame as well.

I actually dropped medicare so maybe someone will come up with a solution if the numbers of docs start dropping out in large numbers.

But in reality, defining care(prospectively) that has no chance of any benefit, and could only cause harm, is difficult. Such care would be a small fraction of the care the M.Mahars of the world are talking about. If we truly are going to control costs, we need to cut out the care that reasonable clinicians agree is unlikely to provide much benefit for the costs incurred.

So you don’t get dialysis, even though you might live a few more months. You don’t get the dementia medicines that provide little benefit. You don’t get your hip replaced if you don’t have a reasonable lifespan left to use it. You don’t get the experimental chemo that may (if you’re lucky) give you 3 more months of life. and on and on.

Care in these situations, (and countless others) provides some benefit. It’s simply a small benefit, and not worth our limited resources. If you as the patient aren’t paying, it may be worth it. But it’s not to the rest of us, which is the issue.

Pretending that there is a dichotomy of 1. Proven useful care that is worth it (all the time), and
2. wasteful inefficent care that is not worth it (ever), completely dodges the issue. Not all benefit is worth the price paid. But everyone wants their potential benefit.