Health policy experts have never been shy about their antagonism towards doctors.
The focus now appears to be on physician pay, with the Washington Post’s Steven Pearlstein, for one, continuing his anti-physician columns. Derek Thompson, over at The Atlantic (via @AllergyNotes), continues the assault, with a recent blog entry wondering if doctors deserve to be paid less.
I touched upon this topic last year, in a USA Today op-ed, Doctors’ pay cuts save little in health care costs, and paraphrased prominent Princeton economist Uwe Reinhardt saying that cutting physician pay 20 percent will only result in 2 percent of health care savings. And besides, if the current system stays in place, doctors whose pay is cut will simply respond by doing more procedures.
Furthermore, many health policy experts bring out the tired statistic comparing American physician salaries with those abroad. The problem is that these are not apples-to-apples comparisons. Both the cost of medical school and malpractice insurance are exponentially higher Stateside. Fully subsidize medical school and bring malpractice premiums down to the levels of other countries first, before talking about tackling doctors’ pay.
Until then, comparing physician salaries with those in Europe is a largely meaningless exercise, and only serves to expose many health wonks’ innate contempt for the medical profession.
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The Gawande article (which most health care pundits were so quick to praise) hasn’t helped matters either. Remember, Gawande concluded that McAllen’s problem was a “culture of money” that had infected its physicians. Then he sets up an either/or scenario of the Mayo Model (collectivist, salaried, patient-first doctors collaborating as a giant happy Waltons family) versus the McAllen model (greedy, me-first physicians who own strip malls and apartment compexes and nefariously self refer unnecessary procedures to themselves), even though McAllen is admittedly an outlier. That article has done more damage to physician credibility than anything written in the past ten years…..
buckeye:
McAllen is only an outlier because it is not a major metropolitan center. The problems within McAllen are not outliers, but exist quite clearly in Miami Beach, New York City, Boston, Philadelphia, Los Angeles, and other metropolitan regions, Check out the map on msn documenting average medicare expenditures per medicare benficiary. The range is tremendous and the outcomes are not different. Studying the map, the conclusion is quite clear: the more specialty medicine, the more things cost.
We doctors have got to admit that we are a big part of the problem.
Kevin,
It’s a great question – I’ve blogged about it several times at See First.
After Pearlstein’s latest rant against doctors, I think the problem is he (and others) just misunderstand doctors. They think of them like stock brokers, trying to make commission dollars pushing questionable stocks. They discount – or don’t think of – the possibility that most doctors go into medicine to actually help patients, and are primarily motivated in this way.
If you look at health care through that lens, you can of course find examples of doctors abusing the system to their benefit, but this isn’t the norm. We need more doctors to speak out on this point and call out those who would try to oversimplify the problems of our health care system by suggesting “it’s the doctors, stupid.”
Evan Falchuk
The denizens of the washington cesspool have always been terrified of anyone who is successful, partly because it highlights their own sense of worthlessness. Even before Milliken and Microsoft, before IBM and Standard Oil, the useless can use the raw power of government to try and make things go their way.
Chuck Brooks
FutureWare SCG
Kevin,
I could not agree more with your thoughts, and suggest that they need to be made more often and more loudly by the physician community. It is clear that the wonks simply take a “scape-goat of the day” approach to answering very complex issues. It appears that they have turned their sites from Big Pharma to physicians without recognition of the nuances of patient care, which readily apparent in the Gawande article. The phrase “with similar outcomes” is often used with little discussion of what exactly that means — the devil is certainly in the details with statements like that.
Full Disclosure: I work for a large biopharmaceutical company and have seen this approach utilized repeatedly to diminish the value that new medicines bring to patient care (admission: we need reform and are working to achieve that end).
I hope for you, and the rest of the physician community, that you learn from our mistakes — correct what needs to be corrected but do not allow unwarranted, unsubstantiated attacks go unchallenged. It is a path that leads to complete devaluation of all that you bring to patients every day.
Best,
Tom
The negative press towards physicians and the tremendous cost of medicine do not come from any one single problem. On the negative physician perspective, I noted on the day I entered medical school, everyone had the same comment to me; “you’re going to be rich.” I was astonished (and I am far from being rich).
The public is convinced that we are all on the golf course and going to fabulous getaway’s in Tahiti. Until the public understands that specialists like myself work 100 plus hours a week and don’t earn nearly half of what they think I earn and that primary care doctors have to see 50 to 75 patients a day to keep afloat… well.. we will continue to be vilified. Our fore-fathers of the 80s to 90s really hurt us tremendously by their excess.
Today’s excesses are born of a different problem. Society demands that we do everything possible to improve their health and do it to perfection. They ask the medical profession to “make them better”; many times caused by their 20 plus years of unhealthy lifestyle choices. It is no secret that we smoke too much, eat too much, drink too much and exercise too little. Couple this with the the following: 1. Dramatic improvements in diagnostic devices and therapies. 2. Rapid growth of pharmaceuticals. 3. Ability to treat people with catastrophic illnesses due to the growth of intensive care units.
Let’s also look at a few changes in health care since the 1960s. 1. If you had a heart attack, you either lived or died… no emergent CABG or Angio.. no CCU… if you made it.. you’re doc told you to move to Florida. 2. Kidney, Lung, Heart, Liver failure… No transplant for you. 3. Stroke. Good luck. 4. Cancer.. I can’t even scratch the radical changes here. 5. Trauma.. no such thing as a Trauma Center until the late 1970s.
It is clear that we need radical health care reform. But this reform will not happen if our society is unwilling to reform themselves. This health care pie is only so large. We must make tough decisions about how we will slice the pie. But we need to educate our public that their physicians are more of the solution than the problem.
JFS
i would gladly take a paycut in exchange for elimination of all the bs we in our profession go through- educational loans, the threat of lawsuits, disrespectful/abusive patients, insurance hassles, admin with no clinical training telling us what to do, satisfaction surveys that are more important than patient outcomes…
just be aware that many would-be applicants won’t necessarily feel the same way, and without the promise of financial success won’t be willing to endure the torture of training to become a physician. which is worse? greedy doctors who are in it for the money or no doctors at all?
i totally agree about subsidizing the med edu and solving the malpractice litigation issue. this would only help with reducing the health care cost but also attracts more people into medicine.
Interesting to compare and contrast CNBC reporters’ justifications of TARP bailout recipients’ bonuses to CDO traders, with their critiques of doctors’ ‘high salaries’.
Pearlstein and Thompson fail to realize that decreasing physician compensation forces physicians to increase volume. More office visits, more procedures, more lab tests. Physicians have underlying costs that they can not correspondingly decrease: they still need to pay for an office lease, secretaries, and nurses.
If the goal is decreasing overall healthcare costs, physician compensation should be increased so there is less pressure to increase income by increasing volume.
Doctors’ and nurses’ future performance are monetized bundles of ‘uncollateralized debt obligations’ (UDOs) of entities collecting insurance premium profits.
Who is the guarantor?
Like it or not, the sheer cost of providing healthcare in the US is a major contributor to high overall costs, and a good part of that – given that healthcare is labour intensive – is salaries/fees, not just for physicians but also for administrators (the head of a large American hospital can earn a million dollars or more – much more than say a European counterpart). I don’t see any doctor hating going on here – the key argument is basically about inequality overall in America where huge differentials exist between the rich and poor, more so than most other developed nations.
Kevin, Perhaps health care wonks hate doctors because they are so resistant to logic and fact–and are only concerned with their own salaries and prestige.
I have no idea what paraphrase you’re doing of Uwe–but as the McKinsey Foundation report shows conclusively
http://www.mckinsey.com/mgi/publications/US_healthcare/
the cause for higher costs of healthcare in the US than in peer countries IS DOCTORS’S SALARIES.
As for the stupid apples to oranges argument, it just shows your lack of facility with logic or accounting. First, areas with relatively low malpractice like dermatology make oodles more than their European counterparts. Thus, medmal can hardly explain the Euro-US difference.
The incremental cost of medical school again is minor when amortized over an entire career. Again, the average UK doctor makes around 140K; the average US doctor around 300K. Med school costs around 200K, say 300K if you want to include opportunity costs. HMMM . . . . looks like the U.S. doctor recoups his investment in 2 years.
Kevinmd, we health wonks hate doctors because you only care about your own wealth and status. The sooner doctors are silenced and eliminated from healthcare debates the better.
skepticus, thanks for demonstrating the stereotypical innate contempt health policy experts have towards doctors.
Uwe Reinhardt’s citation could be found here:
“Besides, cutting doctors’ take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians’ practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.
This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy. ”
http://query.nytimes.com/gst/fullpage.html?res=9B00EEDE163AF936A3575BC0A9619C8B63
Thanks,
Kevin
Go ahead and try to reduce doctors salaries and see how many people want to enter medicine. I can tell you most people in my medical school class would have NEVER taken on 300K worth of debt to get paid what a nurse can make these days….
Being put on the defensive is never a winning position. It seems at this point the only way to force understanding is to demand legal professional conditions similar to those of medicos, and quit the traditional practice of medicine.
Let society do without for a while as it decides how best to divide the healthcare dollar.
Average UK GP makes closer to 140K – POUNDS maybe.
When I ask UK GP’s they describe something more like US$200K income. Consultant specialists still do much better, depends how much private work they want to do.
Average USA physician is $300K ??
I’m doing something seriously wrong.
Ah, Kevinmd, so indifferent to facts and truth.
According to the 2007 McKinsey report, US healthcare expenditures are roughtly 500 billion more than expected by international comparisons. 85% of this amount is due to physician and hospital costs. I have no idea where Uwe’s getting his numbers.
But, let’s say he’s right. 2% reduction is costs is not inconsiderable. Ahh . . . but medmal costs are usually figured at around 1%. You get awfully worked up about that 1% but defensive about savings that could be TWICE AS MUCH. Are you illogical or self-interested?
As for illogical, isn’t Uwe Reinhardt a healthcare wonk. He’s not hostile to doctors. Maybe you’re just reacting to those wonks who are and trying to pathologize them. Wouldn’t be the first time doctors have tried that strategy.
As for the scare of doctors leaving medicine. Doctors went on strike in Israel in the 70s. Deathrates dropped. The Dartmouth Atlas has shown no relationship between number of doctors in an area and healthcare outcomes. Leave medicine–you’d be doing us all a favor!
Would someone please define normalized “physician salary’?
Net hourly wage, especially net of malpractice premiums– which no other profession seems to require, would be a fairer comparison of professional compensation than gross annual income.
While calculating, be sure to include physicians’ 4-10 year unpaid or low-paid training years, when other professionals are enjoying earnings enough to save and compound toward retirement… Or are being subsidized toward retirement and provided ‘free health care’ by employer plans.
How can we conscript all these workers with medical-envy into service? Perhaps having more workers willing to tolerate current employment conditions would lower healthcare costs.
@arf: Roger that! I’m clearly doing something wrong.
Skepticus,
Obviously, you are new to the healthcare scene. You are hashing out myths that have be disproven over and over again (if you dare quote infant mortality I will snap). For example, how can you lump doctors and hospitals into the same group. DOCTORS ARE NOT HOSPITALS. Hospitals include nursing, ultrasound, phlebotmoist, janitors, cafeteria, etc.
The cost of our law system does not come from teh cost of trials which still stands at a staggering 1 percent like you said (just think how much this truly is), but it comes from defenensive medicine or what I hear everyday called CYA. In my training, we have built in algorithms of CYA medicine that have now become standard of care for no other reason then to protect us from lawsuits. We know what the test will show exactly 99.9 percent of the time. Basically, I just gave a chemo patient about 50,000 dollars of the best antibiotics for the last 2 weeks because she was spiking fevers that were most likely a result of chemo.
But if this patient had become septic and died we would have lost millions. So tell me… have you factored that 50K into your estimates. Now, rinse and repeat every day of my life over and over and over. Before you say that I do this to make a profit let me assure you that I don’t. I am paid on salary as are all my attendings.
Finally, if you REALLY believe that not seeing the doctor will improve your health then by my guest! No one is forcing you to go to the doctor. No, but when you get a lump you’ll be the first one to seek out a onc doc. I really hate hypocrites.
The reason policy wonks hate doctors is because they blow budgets by keeping people alive.
residentdoc: No one has been able to measure–or detect–defensive medicine. Kessler tried in a very complex model in the 90s. They’re big problems with it; other researchers have failed to find a relationship between likelihood of lawsuit and “defensive practices” And, yes, hospitals are not doctors– must be all those janitor salaries that are driving health care costs. The one percent includes insurance payments. The cost of trials are bourne by insurance companies,not the healthcare industry.
Susan H: Again, do the numbers. US doctors on average make sevearl 100Ks more than their European counterparts. Amortized opportunity costs (incremental to you next best choice in occupation, remember everyone needs a graduate degree these days) and direct cost of medical school and medmal (particularly if you’re a dermatologist) doesn’t get you there.
Dr. Wes. . . . our heroic little doctor. You blow budgets for sure. Save lives? Albania has a life expectancy that’s less than 1 year shorter than our own. It spends about 1/100th per capita on healthcare. For every life you guys save, you’re probably killing someone else.
Skepticus it is not so hard to answer a straightforward question, unless you do not like the answer.
The question was: what are NET hourly wages of U.S. physicians on a normalized basis?
“do the numbers. US doctors on average make sevearl 100Ks more than their European counterparts.”
I believe the hours worked by European doctors are far fewer, and the potential medmal liablity(thus medmal insurance overhead cost) is limited.
I
Susan H–
I don’t even know what you’re talking about when you refer to the “hourly wages of U.S. physician on a normalized basis.” Normal to what? Are you trying to be statistical?
Some European doctors work less, some more. BUT, virtually all American doctors make more than their Euro counterparts even in fields with low malpractice like dermatology. Medmal isn’t driving the wage disparity, people.
Physicians routinely claim that we need a European style approach to our medical malpractice system and extol the virtues of Europe in this regard. Putting aside the fact that they don’t really know what they’re talking about with European systems, they never acknowledge the fact that universal healthcare and deeper social safety nets take a lot of the need for malpractice away. Now they want to complain that others do it to them?
A bit hypocritical to complain about othera doing the same thing don’t you think?
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