Comments on: Successful health reform requires changing physician incentives, my take in The New York Times

By: Kristen

Kristen — Thu, 20 Aug 2009 15:51:16 +0000

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.

By: Michael

Michael — Tue, 07 Jul 2009 19:08:22 +0000

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.

By: Joanne Gere

Joanne Gere — Thu, 25 Jun 2009 14:09:20 +0000

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.

By: Donna Baver Rovito

Donna Baver Rovito — Thu, 25 Jun 2009 13:41:56 +0000

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.

By: Scott

Scott — Wed, 24 Jun 2009 15:19:07 +0000

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.

By: Matt

Matt — Mon, 22 Jun 2009 13:37:04 +0000

” that specialists are in short supply too.”

Really? How many should we have? How many do we have?

By: J R

J R — Sun, 21 Jun 2009 08:50:07 +0000

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.

By: Justin

Justin — Fri, 19 Jun 2009 21:55:44 +0000

“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.

By: anonymous

anonymous — Fri, 19 Jun 2009 15:27:16 +0000

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.

By: Susan H

Susan H — Fri, 19 Jun 2009 15:00:43 +0000

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.