Can doctors resist the temptation of money?

Great piece, Kevin, as always! We need restructuring of our misaligned incentives. But also I like to talk about the demoralization that being driven by only external rewards engenders in any profession — we see this in medicine. I recently did a very unscientific and very informal online poll in a MD chatroom, where I found that 27% of the responders feel demoralized occasionally, 13% frequently, 47% most of the time and 13% all of the time. No one answered the question “Do you feel demoralized by today’s state of medicine?” with a “never”.

I wrote about demoralization in this post: http://evimedgroup.blogspot.com/2009/06/reduce-destroy-demoralize-or-why-single.html

Marya

Evil doctors are deviants because they want to earn a living, and we should all sit at the campfire singing “Kum-ba-yah being happy docile slaves to the government and insurance companies.

Give me a break.

Every human being on the planet, regardless of occupation, is motivated by money. To deny it is like denying the tides, denying sunrise and sunset.

Pay fee-for-service, there is an arguable motivation to overtreat.

Put every doc on salary, there is an equally arguable motivation to undertreat.

There have been articles in the UK medical press about cancers felt to be curable at the time of diagnosis, that become incurable at the time of surgery, just because of waiting times there. To the extent that happens, this is more than a theoretical argument.

MED PAC is part of the solution which white house is endorsing. It will be non patisan entity, have a board of doctors, researchers who will take time to look at data and do comparitative analysis. Doctors regularly don’t have time to pore through tons of informationa and have no incentive to see if blue pill works the same as red pill but red pill costs 50% less. Stable angina getting 3-4 stents without discussion of long term prospects is actually harming patients and costing us more. To have doctors voluntarily practice the best possible medicine is like expecting the moon. Obviously, it will be a difficult road but we need to start doing the right things. Bundled pay for the visit will enhance the chances as there is no incentive to over treat and evry incentive to coordinate with others and patients will benefit. As a rule, no doctor denies care for patients( it is doctor’s nightmare if they do) but plenty of them overdo even not needed which is what we need to address effectively.

SmartDoc is correct. Most Americans want their health care like McDonalds food – they want it cheap, convenient and SuperSized. That is they get all they want. The results are the same: it is bad for you but there is still a long waiting line in the drive through.

I agree with you on MedPac. They should be allowed to evolve into an organization that will set the standards for “positive deviants”. And I can’t wait until they butt heads with the American Bar Association because that will happen as soon as a Doc can turn to MedPac endorsed guidelines to justify his practice decisions.

I am a medical student who isn’t looking to go into a high-paying field or use my patients for revenue, but I can see their temptations when a new resident is stuck with six-figure loan debt. I myself will be one of them. If there is to be physician payment or reimbursement reform, there must be better financial assistance or reduced tuition costs for students entering medical school as well. I believe this can level the competitive field for many specialties and drive more high quality, young physicians back into primary care.

K
You are probably treated like a McDonalds customer because you pay your Doc a $10 to $20 co-pay and he then has to bill your insurance company for the discounted balance that he has had to contracturally agree to because he has no collective bargining power. Then he has to wait 3 to 6 months to get that payment and from that payment he has to pay a 50 to 60 percent overhead before he pockets any of the money for himself. That is assuming you do not have a pre-existing problem and he gets the coding and the paperwork to your insurance company’s satisfaction. If he doesn’t then he has to copy your records , at his expense, send them in to your insurance company and wait another 6 months. In the meantime you have gotten your treatment. You may not have liked it because you thought you were eating at the best steakhouse in town but your doc gets paid from the “dollar menu”. Is this fair to you? NO. But as long as there is someone who’s between you and your doctor and they are writting the check then you will get the “dollar menu” care and the doc is going to ask you if you want to “SuperSize” it.

“Is this fair to you? NO.”

So that justifies risking my health with unnecessary treatment.

My insurance company pays on the Monday after I see a provider if done electronically. I pay $40-$50 for my 10 minute appoinment. My insurance is one of the better paying in my area. Do you really think I have a choice to go without insurance? If I paid you cash you would treat me appropriately? Do you sign those contracts because you think it’s ok to pad the bottom line with unnecessary treatment? Ultimately you are saying money is more important than my health. You’ve traded your soul for money. If you don’t like what my insurance pays, then don’t accept it. Don’t treat me like a cheap commodity-just let me suffer and die. I don’t want you to feel I ripped you off.

.

K
Who knows what you do to earn a living, or why you justify being paid to to it. If you tried to explain the details justifying your paycheck to an audience of customers they may not understand, or even care.
But I promise you, friend, you are being manipulated into anger against the one profession in capitalist society that does indeed care.

You are certainly free to refuse to purchase any goods and services for sale in America. The internet is full of diagnostic tools, anatomy books, treatment plan recommendations, and chatrooms of patients with similar conditions. For standards of care in your state you may want to look up case law, and let that guide your self-treatment plan.
Serum testing facilities are springing up, and offer reasonable pricing for common blood or urine lab tests.
If you feel you need pharmaceuticals, there are books which describe how drugs work, side effects, interactions, and other data you will find you need to know before you insert a foreign substance into your body.
If you feel that restrictions on self-presribing are a violation of your right to life, contact your legislative representatives to lobby for deregulation of controlled medications.

K – “…….I would be willing to pay for a competent, caring PCP……”

I’m sure you are. I do know I’ve inherited a number of thyroid patients and diabetic patients, because their endocrinologist joined a practice that’s insurance-free. They would pay about a thousand dollars a year out-of-pocket not paid by insurance, for the services of that endocrinologist.

Personally, I’d say for the dollar factor involved, it is a reasonably good deal for someone with endocrine disease.

The endocrinologist is a fine doctor, caring and listens and all that.

I now have a number of patients who feel differently from you. I like to think I’m good, but if I went insurance free like that doc, they’d be out of my office just as quick.

K
‘You’ve traded your soul for money’
I find your comment HIGHLY offensive. You know nothing about me. You don’t know it to me took me 11 years to get a medical degree and before I had any income. You don’t know it took me 5 years to pay off my educational debt. You don’t know of the family sacrifices I have made to take care of patients at night, weekends and holidays. You don’t know of the hundreds of thousands of dollars of free care I have provided and written off. BUT I know that any patient with your attitude and expectations can not be cared for to your satisfaction for ANY amount of money. by ANY doctor. You remind me of the patient who complained that I had taken a week off to vacation with my family. She “needed me more’. So good luck finding a doctor who will satisfy your expectations and thank God it is still a free country and I can still refuse to see unreasonably demanding patients.

Alex
I have found the following to be true.
” Those doctors that graduated in the top third of their class make the best professors, those that graduated in the middle third make the best doctors and those the graduated in the bottom make the most money”.
Being a doctor creates a lot of opportunity but that doesn’t mean you should take them all. If you don’t know where to draw the line then you may be morally deficient. But doctor must make that decision or the Ks will make it for us

Great post, Kevin, and a very interesting discussion thread. Thanks to everyone for their input.

Patients in this country are frustrated. The problem is, they blame their doctors for their frustration and don’t “look behind the curtain” to see who’s really pulling the strings.

Physicians are the face of medicine but they do not control healthcare. They have also become pawns in the system. Patients get angry and yell at their doctors about the lack of care they receive. Then government and the insurance industry heap more regulations on doctors and cut their reimbursements even more so doctors adjust by pushing more patients through their clinics in cattle cars and running around like hamsters on speed.

When patients (ie- voters) complain about the terrible healthcare they are receiving and yell more loudly about their doctors’ insensitivity, the government and insurance industry smile and explain that this is why we need to give them more of the power over healthcare– because doctors keep screwing it up.

In the minds of most patients, healthcare = doctors. The problem is that this equation was erased long ago. The new equation is healthcare= government/insurance. Don’t worry, though… according to recent proclamations, we’ll be getting a lot more “healthcare” very soon.

this is a very educational and entertaining thread!

Excellent thread.
I’m a physician, in practice. Running a medical practice is running a small business, but a business unlike any other. You form close relationships with your patients, you are often responsible for life and death issues, you need to support your staff also affected by your patients’ personal and sometimes dire circumstances, and then you have to bill for it, make enough money to pay for your rent, insurance, staff salaries (with the occasional raises), and bring home enough to support your family and other responsibilities. I know many physicians, obviously, and I know the vast vast majority of them care way more about their patients and their patients’ health results than they do about their own incomes. Mostly we just want to make enough to survive another day to take care of our patients. Most doctors aren’t greedy, I’m sure of that. We don’t get much business training, learning about business “on the job” and often feeling angry and used when our insurance contracted payments decrease year to year while our rent and staff salaries go up.
Somewhere in all this discussion there’s a “fair” payment for the work physicians do (and their investment in time and money that got them to be the skilled caring physicians they are), and that the patient receives. Maybe the free market can determine that. I doubt that the government or any Insurance company (with executives and shareholders to satisfy) can determine that price artificially. In the meantime I think the moral and ethical course is for physicians to learn about business and try to be as efficient and logical as they can be in their patient care treatments and recommendations. Over the longer term though, the system has to change so that new physicians don’t emerge from medical school with huge debt, and tort reform makes the legal system fairer to everyone (ie docs too).

Solutions for Healthcare:
Surely, as a teacher, and mathematician, you can see that “the money” isn’t gushing into your human medical service provider’s pocket…that there is overhead, and liability cost, and that ten minutes in your presence is only part of the time spent on any patient’s case? And that your anger would be more productive if focused on those profiteering from the system who have true malice and selfishness in their hearts?

You must have had some failures as students: no matter what you tried as a teacher, using all your training and all available reference material they just didn’t get it..well, not all human bodies’ discomforts or diseases can be diagnosed or treated to client satisfaction.
I am so sorry if you feel pain, and especially sorry of you feel abandoned. Human to human, I believe no one gets abandoned. Systems are allowed to abandon individuals in the pursuit of highest good for the most members. It sounds like you are ‘in the system’, and doing a good job of trying to help yourself as one of the system’s outliers.

You are either paid by the system(including health ‘insurance’ and pension benefits) or are a sole proprietor tutor. If you receive benefits and guaranteed pay, please use logic, to allow that medical providers have a very different business model than a salaried employee. If sole prop., please factor in the enormous, unique-to-medical-profession, liability risks/expenses borne by these medical providers.
As a fellow human, I sincerely wish you good luck with your health.

This is a great topic!

In my line of business I have this conversation to a certain extent every day with Dr.’s. No kidding, every time I step into an appointment its always the same response when asked ” what would you change in your billing if you could?”. I always get the same answer 99% of the time ” I would like to get more money out of my billing!”. This is nothing new to me and I have to admit at first I was skeptical of the Dr.’s ethics when hearing this answer but after further research and many conversations covering the same results, I know why Dr.s reply with this answer. Not to any surprise to many of you but many insurance companies dictate what they will pay and what they will not pay even though you code the bill to specific approved codes. That doesn’t seem fair and so the questionalble debate arises with the scenario of Dr.’s giving the “on the side Botox injection”. Maybe if the insurance companies would pay for what the coded procedure promises this would never be the case but in reality its not. Not to mention that Dr.’s simple do not get paid what they used to.

So within you will hear my solution to this small part of the problem. And in saying that I am going to start out with my frustrations of this repetitive topic.

In my line of business you get the infamous gate keeper! Here are the types that will hurt/kill a business (and I talk to these guardians more often than not!): 1) the person answering the phone and does not pass the message on or stops you immediately from getting past them, 2) the person (often practice manager) that fields the appointment but neither has the authority to make a decision nor has the knowledge of what the Dr’s. needs really are, 3) the Dr. (yes I said Dr.) that has been with the same system for years and either simply will not change OR they do not know what the compitition has to offer, in other words do not know what else is out there and my personal favorite 4) (sigh) the billing person (manager) that is afraid that I would take their job regardless of the fact that what I have will save the Dr.’s business thousands and thousands of dollars each year. Honestly, I don’t see the last that often but nevertheless, I do run into it occasionally and I say its my favorite in passing becuase this selfish, egotistical act is the primary reason why it is costing the Dr.’s business money rather than gaining money…..the literal contradiction of having a billing person on staff- to insure money coming in (wheres your ROI on that?). Any of these combinations will yeild less money than gain in any business.

By using new technology and streamlining processes, primary care practices can reduce their costs to half of what a typical practice pays, from about 60% of income down to 30%. To quote TampaDoc ” am sixty years old, working non stop with a 70% overhead. Employing personnel to satisfy insurance mandates…. somone to verify insurance, someone to do pharmacy overrides, someone to fill out forms, someone to get approval for radiologic studies, etc…” So not all of you are 60 years old but this is a very common and realistic scenario in owning your own practice.

Again, this is only a solution to a small part of the puzzle . I met with one practice and saved them $36,000 a year, another practice I saved them $28,000 a year and they actually had used the same system for over 15 years……do the math with that one! Also they were looking at a 35+ day return on their bills! How does that work? Now add in their 40% of rejections and to top it off think about the time frame on their past due accounts.

So in consideration of the topic (and I hear this every day at work because the money aspect of medical practices is my line of business), this should be a self evaluated question on what Buckeye Surgeon poetically put it ” the proposition that our healthcare woes are entirely physician centered….”. Of course money matters and being able to retrieve your money is not a greedy ingredient!

So my solution is to start in house and look at your A/R’s. What can you change there and what is out there to best assist you in your analysis? I didn’t post to start an advertisement but come on Dr.’s…..the same repetitve question can be answered and I can give you a side by comparison of what your current billing system is compared to mine. Please contact me @ aperez@fortsonservices.com . Whats there to lose? Maybe if more Dr.’s were getting paid what they are supposed to get paid from the insurance companies this wouldn’t be an issue.