I have a piece in The New York Times’ Room for Debate blog, discussing how reforming physician incentives is a key to health reform.
Here’s an excerpt:
Some health policy analysts blame the medical profession entirely for the role they play in rising health care spending. And indeed, doctors have tremendous influence in the tests being ordered and treatments prescribed. But singling out physicians would be like blaming the players for a proverbial game’s flawed rules. More important than focusing on the players, we need to change the rules.
As a bonus, emergency physician Shadowfax, who eloquently blogs health policy and ER issues over at Movin’ Meat, also provides his take:
What we need to do is rebalance physician compensation away from procedures and toward primary care. Surgeons can easily earn three to five times the average salary of a family doctor. The compensation for surgical procedures should be reduced, and the savings realized should be applied toward increasing pay for primary care physicians.
Enjoy the editorials, and thanks to The Times for the opportunity to write for them.
Related posts:
- More coverage requires more doctors, my take in The New York Times
- Physician tiers and advertising in the NY Times
- President Bush, lauded by The New York Times? On health care?
- Health care reform needs to improve physician satisfaction
- Op-ed: More coverage requires more doctors
- How will the media influence health reform?
- Talking health care reform in Congressional Quarterly and WORLD Magazine
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“The compensation for surgical procedures should be reduced, and the savings realized should be applied toward increasing pay for primary care physicians.”
Good luck with that.
Kevin, you are a doctor advocate. You know full well that surgeons train hard, they are there day and night, take care of life and death emergencies at the drop of a hat and never ever hand over responsibility of a patient under their care. Do they not deserve their salaries. It is true that PCPs need to be paid more as they are the gate keepers to health. Is taking it away from the surgeons the answer?
I am a primary care physician. And still I think Ralph is right. Surgeons do not get paid as much as the amount of effort they put in it. The bundling of an operation and all follow up appointments is simply ridiculous. Imagine if any of the PCPs have to do free follow up visits after treating patient for a medical problem! If that happens then PCPs will have no option but to close their practices as they will not be financially viable anymore.
On the same note PCPs are definitely being paid less. And to get more physicians to enter primary care – the compensation has to be increased. If not, the dream of universal healthcare will cover all patients – but will have no physicians to provide it.
The major expense of healthcare is from drug companies and equipment etc. We all know it does not cost 35K to manufacture an AICD. A pill sold for $10/- costs one cents to make and probably another 20 more cents if you include research costs. The companies all have lobbies and whenever the question comes about cutting healthcare costs, these lobbies influence lawmakers to focus on physician compensation – just to take the spotlight away from them.
EASILY earn 3-5 times as much as a family physician. What a load of crap. Shadowfax has no clue how hard and many hours a surgeon would have to do to complete that feat. EASILY give me a friggin break. I’ve seen FPs make twice as much as a surgeon as wellI know its hard to imagine when you do shift work for a living. If they do increase the reimbursement, maybe no specialists will be there to take his phone calls from the ER because its more lucrative to be in the office.
Did you mention any of these self-evident easy savings?
http://supremacyclaus.blogspot.com/2009/06/lower-health-care-cost-by-50-by-getting.html
Wow. Shadowfax, God bless him, is extraordinarily naive on this one. Our reimbursements have dropped 30% on things like hernia repairs and lap choles over the past 10 years. When you take your car in to get the oil changed, are you paying 1998 prices or $39.95? Does your haircut cost the same as it did when you were in high school?
Factor in the whole global period travesty (that 70 year old with medicare who shows up in the ER with a perfed diverticulitis and you end up managing them in the ICU for three weeks, all for the same low bundled price!) and it’s easy to see that general surgeons have been getting squeezed for years. You can’t possibly wring anymore out of the income flow of a typical general surgeon. We work longer, do free surgery (all those uninsured 20 year olds with appendicitis), endure more stress, and we’ve trained longer. I don’t have any problem averring that a general surgeon probably ought to be compensated accordingly.
This Gawande article unfortunately has ignited a “doctors are greedy” craze and it’s being held up by the likes of Peter Orszag as a shining example of what’s wrong with American medicine. And it’s a ludicrous article. I urge every physician to re-read Gawande’s piece, this time critically. Basically he spotlights an outlier region of America and holds it up as a shining example of what’s wrong with healthcare. It’s incoherent. Sure McAllen represents a quicker way to go bankrupt but we didn’t get into our current troubles because places like McAllen are common. There’s something deeper going on. Kevin makes a good point above: “And indeed, doctors have tremendous influence in the tests being ordered and treatments prescribed. But singling out physicians would be like blaming the players for a proverbial game’s flawed rules.”
As physicians we can certainly do better. But the game isn’t set up in our favor. It’s easy to oversimplify something as complex as health care reform by attributing all blame to a single entity, i.e. greedy docs and their “culture of money”. But it’s much more complicated. Overutilization doesn’t always have a simple dollars and cents causality. We do a lot of things that aren’t necessary, not out of financial incentives, but rather from lack of thinking, lack of clinical insight. That’s what needs to improve. PCP’s need to be allowed to spend as much time as needed with their patients. Make this financially feasible and everything else will fall into line; the needless consults, the ridiculous MRI’s, the over-reliance on some procedure to magically make everything better, it will all dissipate on its own…
I wrote about this on my blog earlier this week. I hope I’m not the only physician not drooling over the NewYorker piece…
General surgeons are feeling the squeeze like primary care docs, and, in the same way, fewer students are choosing to enter the speciality.
The redistribution needs to come from derms, paths, rads, anesthesiologists, orthos who do elective (and unindicated) laminectomies and knee replacements; and from the enormous support industries that have grown up around them.
“More important than focusing on the players, we need to change the rules.”
Perhaps physicians need to recognize the role they can play in setting the rules, and stop waiting for others to do something. They keep signing up to play the game year after year, and keep making the same old gripes. Taking control of their own destiny might help physicians and patients alike.
When you take the governments money, you play by their rules. The consequences of centralized pricing will always declare itself. Right now it’s the destruction of primary care. The question now is who is next. It’s the race to the lowest common denominator. If you aren’t happy with what the government is paying you, stop accepting their money. When enough physicians say no, the pricing problems will fix themselves
Can’t the whole problem be normalized to this statement:
“Nobody would do this job under these conditions.” ?
I think you could accomplish much by forcing this statement from the lips of those who devise the rules and craft the system. Nobody seems to care when they hear doctors saying it.
I suggest simple mandates to make personal injury attorneys liable for pain and suffering damages for legal malpractice, and allow recovery of such damages as malpractice premium hikes, mental anguish, and attorney fee recovery in cases of malicious prosecution or abuse of process.
Finally, insist that judges be personally liable for professional malpractice. Any decision overturned on appeal is prima facie legal malpractice.
Forcing these issues to be discussed and defended by the rulemakers might bring an aha moment to the voting public, if nothing else.
I believe that Kevin forgets when he rails against specialist income that specialists are in short supply too. The best way for the government to pass their healthcare plan would be just to suck it up and stuff ALL physicians mouths with cash. This wouldn’t even take that much money!!! The savings they are going to get from cutting physician pay will be nowhere near worth the amount of trouble this will cause.
“The redistribution needs to come from derms, paths, rads, anesthesiologists….”
Whoa there, Anesthesiologists currently get reimbursed 33% of private insurance rates by Medicare compared to 80% that most of our peers in other specialties receive. This is already not a sustainable model and yet you think that you can bleed a turnip?
The thinking that cutting physician salaries, while politically convenient, is misguided and contrived. Physician salaries make up a small piece of the healthcare pie but pieces like the one in the New Yorker make it sound as if we are rich, greedy fat cats out to fleece our patients.
Why are most physicians foregoing primary care and entering specialties? Not because they want our health care system to improve. Pure and simple – the main motivation for most physicians is money. There are other motivations of course, but compensation is the major motive. The facts are: The US spends more on health care than any other nation but its results are not the best. Why? Physicians, malpractice attorneys, insurance companies, drug companies, and patients all profit from US health care, and changing to a universal system will cause all of these people to profit less. Thus, each of these entities will place blame the others for the problems without owning up to their own transgressions. It’s not that only physicians are greedy – HUMANS are greedy and it is only human nature to take care of your own needs first.
” that specialists are in short supply too.”
Really? How many should we have? How many do we have?
I agree that increasing the number of primary care physicians and the incentives for primary care is an important goal. Improving access to basic health care is important in improving the overall health of society. What I am not sure about is that it would truly reduce cost. I am not sure how effectively decreasing the number of procedural specialists and increasing primary care would hold down cost, unless as a by-product of that event, access to care was limited by fiat. The cost of a product is usually determined by the cost of production and delivery as well as demand. As an example, producing, delivering and implanting a knee joint replacement is a very expensive process, from the cost of R&D and skilled manufacturing, to the hospital OR where high tech equipment, anesthesia and drugs are used, to the post-op recovery unit and rehab unit, to the operating surgeon’s (the installer’s) fee, the surgical nurses and medical consultants, physical therapy and rehab devices such as crutches and walkers. Of all of these costs, the surgeons fee is a small but crucial fraction. Without the surgeon taking risk, paying high malpractice and working, there is no joint replacement. Without arbitrarily limiting access, I don’t see that any decrease in patient demand for such a proven, life changing procedure is going to happen. How is simply decreasing the joint replacement surgeons fees and increasing the primary care doctors fees going to decrease societal demand for knee replacements, a high tech and expensive procedure? There also seems to be a feeling that all of these procedures we do are unnecessary and unindicated. As a specialist, the vast majority of patients I see are referred to me by primary care physicians because they feel their patients need additional care. Why would they send me patients if they felt that further treatment was not indicated? The primary care gatekeepers are deciding that surgery is likely to be appropriate before I see the patient. In addition, a good surgeon knows that doing unindicated procedures is a very fast way to get into trouble. Because of this, surgery is usually not the first treatment option in my practice. Already the wait to see me for a consult is too long and the primary care docs are sending me as many patients as I can handle. As the number of primary care docs increases and access improves this situation will only get worse, especially if the number of specialist are decreased at the same time. How can this improve patient care and satisfaction? I feel that improving basic health care is extremely important, but as an example, one could argue that from a cost to society perspective a knee replacement is more beneficial than controlling hypertension. Many people live their entire lives with hypertension without any outward dysfunction or disability. Only when later in life it catches up to them with cardiac disease or a stroke do we have a problem. On the other hand, I see many otherwise healthy 50 year olds (and even younger) with disabling knee arthritis that prevents them from working or enjoying their lives. Correcting this problem gives an immediate, long lasting benefit to the patient and society. I only raise this point to show that placing value judgments on types of medical care is very difficult and often inappropriate. I can only hope that by the time some of your respondents above want their knees or hips replaced because they can’t walk without pain, that they will not have gotten what they wished for: limited access to care.
Sadly, many physician leaders, like Shadowfax, are buying into exactly what the politicos want physicians to do at this point – instead of looking OUTSIDE the medical profession to solve the problem and reapportion the “pie,” they’re making doctors eat their own to grab their share….pathetic, really, when you think about the REAL waste in the healthcare system, i.e., administrative and legal fees…..but as long as physicians fight among themselves like the politicos want them to, they won’t focus on solving the real problems in America’s health care delivery system.
My take is that we really need to begin with physician education. When any individual spends so many years learning their craft, as is appropriate, they shouldn’t come out with such debt that they’re forced to put aside the impulse that got them started and turn every encounter into and exchange.
Along with all of the reforms that are obvious, a new and reasonable system of support for the education process would go a long way toward developing a next generation of less frustrated doctors who can really focus on patient care and developing knowledge.
Part of the issue here is that we have made a few specialized individuals to be gatekeepers to the hall of good health. When something costs a whole lot because it is in short supply, you dont cut the cost by fiat, you reduce the demand or you increase the supply. I dont see how we are going to reduce the demand in this case,so that leaves us with one option – increase the supply.
Why are we underutilizing our doctors? Why must a flu patient see a doctor in the first instance? There are several other healthcare professionals that can take care of 100 flu patients as first contact, then we can identify that 1 that though has flu symptoms, but has a bigger problem. We can then refer him to the doctor.
The sooner we start using these highly skilled individuals in the appropriate way, the better for our society.
The bottom line is that physician income is NOT what is bankrupting our healthcare system. It should not be the focus of the debate and fankly shouldn’t even be addressed (only in that primary care doctors need to make more; and I’m a specialist!) To become a doctor, one must educate for 6 – 10 years beyond college, loose 6 – 10 years in opportunity cost, and go hundred of thousands of dollars in debt. If doctors’ incomes drop, so will the quality of people entering the profession and these will be the people standing over you with a knife when you are having a heart attack. We should not let the discussion turn into a struggle between primary care and specialists…instead we need to unite as physicians and protect our autonomy, protect our good name and show the country that our salaries on the whole are not unreasonable given the long path to medicine, the responsibility and hardwork. Physicians truly are the only entity in healthcare that actually CARES about the patient; I am infuriated by remarks that denegrate our profession. For Mr. Obama to claim that physicians will make healthcare choices that are not in the interest of our patients in order to make a buck is absolutely insulting. Physician are not like politicians and are not bought so easily. It is my practice to review all options with patients, the risks, benefits, alternatives of each choice and let them decide. I believe in choice in healthcare and am terrified to see it stripped from us. Furthermore, regarding a government option, why not get Medical, Medicaid and Medicare functioning better as an initial starting place. Has anyone else experienced the incredible waste and inefficiencies in our County Hospitals and clinics? I’m sorry, but I have more faith in the medical profession and it’s ability to uphold our hippocratic oath than I do our elected officials. They have proven time and time again that they are incompetent to lead and to manage money.
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