Dear Congress: Listen to doctors on the front lines of medicine

Dear Congress: Listen to doctors on the front lines of medicine

A follow-up to Dear lawmakers: This is what it’s like to be a doctor today.

Thank you to everyone for the positive feedback.  Over 60,000 Facebook “likes”, tweets, and newspaper requests was quite a surprise. I was especially moved by the multiple tweets from hospices, physician groups, and individuals recommending my article. This article really has hit a nerve and shed light on some of the issues at hand in today’s healthcare debate.  I am writing a follow up article to further address some issues.

First, I wrote my original letter to illustrate some sacrifices doctors on the front lines of care make. In order for doctors to continue providing the highest quality comprehensive care, we need our leaders/lawmakers to understand the perspective we face so that the best solution can be found to care for our population.  I do not feel that this particular perspective was voiced on Capitol Hill during the health care reform debate. Yes, there are lobbyists, but they are not those who are treating patients and may not know the nuances that individual doctors can provide.   In addition, I am concerned about my colleagues in private practice (specialists or primary care doctors) whose livelihood is threatened because of the potential cuts in reimbursement (up to 26%).  This measure could force these doctors out of practice simply because their expenses (which rise yearly) are exceeding their declining reimbursement, which has declined steadily over the past several years already.

If this does happen, it may force doctors to stop seeing Medicare patients because reimbursement is usually lowest for this group.  It will take away the physician-patient relationship that is needed for great medical care.   A recent Forbes article explains this.   In my opinion, Congress needs the help of doctors who take care of patients daily to give their advice on possible remedies.

Despite these lingering issues, I nevertheless love my profession and my patients.  Becoming a doctor was the right choice for me; I was interested in science since I was a little kid and am thankful that I can use my education to help my patients and their families.  I have also learned a tremendous amount from my patients.  I cannot see myself practicing any other field other than medicine and I am humbled daily serving my patients.  I definitely would do it all over again as well because I feel this profession is my calling and I get an enormous amount of personal satisfaction taking care of those in need.  Besides, who would go into medicine in the first place with its years of training, long hours, nighttime patient calls, large debt load, delayed earnings, risk of lawsuits, and daily life and death decisions if they didn’t truly care about the human race?  We went into medicine willingly and do the above out of pride and respect.  However, our real concerns rest on the idea that we may not be able to provide quality care to all patients if the tools and resources we need are reduced further.

Second, I was trying to speak for all doctors, not just GI doctors.  People have commented that I was complaining about my salary and the salary of GI doctors. This article was not intended for GI physicians, but, rather, for all physicians.  Not all physicians get paid the same and primary care doctors typically get paid significantly less than specialists.  The article was a personal anecdote to illustrate some sacrifices of a typical doctor who is paying off his or her loans themselves.  I am not complaining about my current compensation.  Doctors do have the highest average salary of any other profession despite the financial sacrifices early in our career.

But I am concerned about the future cuts that may force doctors to either stop seeing Medicare patients or encourage them to do concierge medicine (which charges a premium to patients for access to the doctor).  I have this concern because most of my colleagues in practices have seen their reimbursement cut and their expenses increase. When these two things happen, one either works more hours in the week to make up the difference or their expenses increase until they can no longer afford to see patients without going into debt.  This in turn could lead to the decline of quality advanced health care that Americans enjoy. There are numerous articles out there as well that show concierge medicine is growing.

The way doctors currently get reimbursed is unique to the medical profession.  The charges (bills) that patients see in the mail are not what doctors get paid.  These are inflated numbers derived from contracts between hospitals or groups and insurance companies.  When a hospital or doctor submits a charge (bill), the insurance companies or Medicare/Medicaid depending on the patient’s insurance utilize a fee schedule, which consists of thousands of codes that give dollar amounts for individual procedures or clinic visits (available on AMA website).  Each code has a dollar figure and a relative value unit (RVU) to determine how much to reimburse that doctor.  This is called a “Medicare fee schedule” and insurance companies will pay a certain percentage of the fee based on Medicare.  This can range from 80% to 180% of Medicare depending on the insurance carrier.

If a patient has Medicare, however, one can see exactly what that doctor will get paid based on the CPT code (it varies 1% based on geography) by using the fee schedule.  This is often called the “allowable charge” in patient’s bills.   The revenue the doctor receives is in fact this fee (not the charge) and is set no matter how much the hospital or doctor chooses to charge. To complicate matters, there are usually two different charges in a patient’s bill: a “professional” charge from the doctor, and a “facility or hospital” charge (an inflated charge that only goes to the facility or the hospital, not the doctor).   First, the doctor only sees the “professional charge” (not the hospital charge) if he or she works for a hospital.  This is the charge for the doctors’ services (e.g. office visit vs. procedure vs. MRI interpretation). Second, the doctor only receives a fraction of this “professional charge” because this is reduced by the fee schedule to the appropriate amount.    After all of this, a doctor sees only a small fraction of the original charge (the bill the patient may see) and this does not include overhead expenses the practice incurs (which can range from 30 to 60%).  This above explanation is not understood by our leaders (ie. President Obama) as verified in this video discussing foot amputations in diabetics.

President Obama claimed that surgeons get paid (not charged) “30, 40, 50 thousand dollars” for a foot amputation.  Looking at the Medicare Fee schedule, CPT code 28805 states that the surgeon would get paid $738.90, which is the fee before his or her office expenses are considered.  This $738.90 needs to cover his or her office space, staffing, medical liability, and years of training to have the privilege of performing this life saving operation.  Thus, the doctor actually gets paid 1.4% ($738.90/$50,000) of what President Obama claimed he got paid.   There are other fees for the hospital but these are not related to a doctor’s compensation.  This clearly illustrates that doctors payment systems are confusing for patients and creates much anxiety when trying to decipher a bill in the mail.  It is apparently even confusing to lawmakers and the President who are trying to modify reimbursement yet do not know how doctors get paid.  This needs to be addressed so patients and lawmakers can understand where doctors are coming from.  It also shows that doctors are not getting paid what some patients think as evidenced by some of the comments in the blog.

As Dr. Benjamin Carson recently stated, “it is very difficult to speak to a large group of people these days and not offend someone … the PC police are out in force at all times.”  And if we continue to attack minor points and detract from the point of an article, we will never make progress.   That being said, I have a tremendous respect for lawyers.  Many close friends and relatives of mine practice law and they do noble things for their clients. Nevertheless, I was merely trying to illustrate how the pay structure for a doctor works and used a lawyer as a comparison since lawyers are also hard working professionals, yet get paid differently.

A good example of the difference in payment structure is as follows:  if a patient with insurance has a colonoscopy and the total “charge” is $2000, doctors do not get paid this.  It is an inflated number as described above.  A doctor gets paid only the “professional fee” portion and whatever the Medicare fee schedule dictates (code 45378), which is the same for all doctors assuming they live in the same region.   This professional payment is a small fraction (10-15% depending of insurance carriers) of what the initial total charge may be, and again, this is before practice expenses.  Further, if that doctor comes in the middle of the night to perform this procedure, he or she does not charge extra.  Doctors do not collect whatever they want for clinic visits or procedures.

In addition, if one procedure takes longer than average or is more complex, a doctor does not collect more for that procedure unlike other professions that are paid hourly.  The fee is pre-determined by the Medicare fee schedule no matter how sick the patient is.  In addition, if there is a follow up call and three family members want to discuss results, this is what we do.  This is all part of the one fee and no additional fees are billed.  If that patient calls at 9pm that night or the patient arrives 30 minutes late to an appointment, there is not an increased charge.

This is clearly different for lawyers; even the DLA Piper lawsuit addresses the “billable hour” and the “churn that bill, baby!” approach.   I am not stating the way lawyers get paid is flawed or wrong; I am simply stating it is very different and sometimes this contrast is not noticed.  Do I speak with patients at 9pm and do I spend the extra 30 minutes helping patients get the quality care they deserve?  Of course, I willingly do this because I went into medicine to help those in need and I get satisfaction from this. I do worry, however, that this may not continue to be the case for all doctors if reimbursement models are not modified and doctors’ fees are not corrected for inflation and practice expenses.  They simply will not bring in enough revenue to cover their expenses. Again, doctors’ fees have been declining, are not secure (please read about the erratic nature of the SGR formula), and do not adjust for inflation.

In conclusion, the previous article was intended to show lawmakers what doctors go through before policy changes make it more difficult to provide quality advanced care. We are already seeing a trend towards concierge medicine due to decreasing reimbursement and higher costs.  Unfortunately, this idea will cause costs to be passed on to patients.

We as doctors have a calling to help human beings and we take this seriously.  However, we feel that Capitol Hill needs doctors from the front lines to discuss our issues so that the best reform possible can be made.  Doctors should not be afraid or ashamed to bring these issues up.  It is only by logical thoughtful discussion without the distractions of the “PC police” that Americans can move forward.   We owe this to ourselves and to the millions of people who look to doctors to treat their ailments.  There are definitely other issues that could be addressed, but it will take Congress to seek out actively practicing doctors (not lobbyists or lawmakers) with experience on the front lines of care to help them arrive at a fair system that can benefit everyone and shed light into the current issues.

We need this to preserve world class health care and to keep our talented patients healthy.   And that is my hope.

Matthew Moeller is a gastroenteroloigst.  This article originally appeared on CaduceusBlog.

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  • http://twitter.com/eyecolumbus Eye Doc Columbus

    Fantastic article. This article does a great job of breaking down the differences between charges and actual reimbursements. Although it is noted I feel that it is important to point out that the “doctor” doesn’t pocket the reimbursements. Typically the “practice/business” collects this much lower rate and the “doctor” only collects a small portion of it. Many times patients feel that their doctor pockets that $20 co-pay for his/her 30 minutes of patient care. But the reality is that with the increased cost of healthcare and expenses, the doctor’s actual percentage is decreasing pretty significantly.

  • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

    NO other professional would accept being treated the way physicians are treated.
    It’s time doctors act like the professionals we are.

    Give:
    Do whatever it takes to get the job done efficiently and with high quality.

    Treat patients with the respect a professional grants any client.
    Be Proud of our work.

    Demand:
    Proper pay.
    That politicians and lawyers stop practicing medicine without a license.
    Stop allowing ourselves to be bullied by insurance companies and organizations that demand unfunded mandates.

    If we can not come together on these basic truths as a group of professionals, we might as well accept that we are simply civil servants directed by an administration….
    and all the joys that come with that.

    kind of sad that we cant seem to get “mad enough” to stand up for ourselves or our patients.

    • buzzkillerjsmith

      Standing up wouldn’t work anyway, at least for us PCPs. I don’t know your field. There are too few of us and we’re too disorganized. A couple years ago I had the pleasure of talking with the AAFP President at a conference. Smart guy, nice guy, he completely understood the fix we’re in. He was completely ineffectual at making any difference for us family docs, as have been those that came after him.

      I made my mistake years ago and will continue to pay for it until I retire, indeed, even after because of lower retirement income.

      Other professionals, specifically teachers and injured military officers, put of with worse things than we do.

      People who put others before themselves are generally abused in this society. That is the way it has been, is, and shall be. But you know this.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Actually, according to KFF, Family Medicine is the second largest specialty. If you add in some pediatricians and a small chunk of Internal Medicine, primary care is by far the largest specialty to the tune of about 200,000 individuals.
        So the army is there. Organizing it is one challenge, and formulating a message most likely to resonate well is another. Sigh….

        • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

          herding this group and then paying the bills is an even larger problem.

          physicians are terrible followers and Primary doctors generally dont have the “extra” cash to fund the political battle this kinda “change” would surely wrought.

          I would be happy with a simple unified REBELLION of primary docs to not just ACCEPT what is shoved down our throat.

          we have lots of power…. agreed. We simply just dont have the will rebel in a single voice.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Not “simply civil servants directed by an administration….”
      It’s worse. More like, simply employees exploited by corporations….

  • trinu

    I think a lot of the complaints come not from patients but from a well meaning general public, which hears about people going bankrupt from medical expenses and assume that it’s the doctors fault. Patients can often see that the majority of the costs come from greedy pharmaceutical companies, insurers, and hospitals, that physicians fees are only a small fraction of the charges, but healthy people don’t see that.

    • kjindal

      and our ill-informed leaders perpetuate the myth of the doctor as cost-driver, as Dr. Moeller so aptly points out with the youtube video.

      • Quill

        I want to laugh at those videos of Obama confirming the worst suspicions of tens (if not hundreds) of millions of Americans that yes, doctors DO regularly do things like unnecessarily amputate limbs and remove tonsils, just for the money…… either laugh, or cry, I don’t know which.

    • buzzkillerjsmith

      About 20-25% of HC payments go to docs, and half of that it is overhead. Our true income is around 12% of HC payments. Most folks would be shocked it is so low.

  • southerndoc1

    Heck, we can’t even get our own medical societies to listen to us, much less the members of Congress!

  • Seval Gunes

    I stopped accepting new Medicare patients and will opt out at the next possible date.
    The daily updates/changes/additions of red tape, regulations, mandates, audits all with the constant threat of Federal felony charges is more that a small practice can bear.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    If Medicare is bad, how about accepting Medicaid? Or is that a done deal…?

    • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

      Medicaid?? LOLOLOLOL
      I once got a check for 16 cents from Medicaid. The check was worth less than the stamp it mailed with.

      • buzzkillerjsmith

        My neurology buddy in CA says he gets paid $19 for a level 3 followup from MediCal.

        • Cris

          “At some point you’ve got to admit that you’ve earned enough money.” — Obama, April 2010

          And with government-funded healthcare, the government gets to decide how much is “enough”. Apparently for a neurologist, it’s $19 per level 3 followup.

    • Guest

      Medicaid is an even poorer payor, if they decide they will pay you at all. The most difficult “insurer” to deal with. Most docs I know will not accept medicaid patients for these reasons, yet the people on medicaid have no idea at all.

  • Mandy

    NO NO NO, all you greedy one-percenter doctors are just out to get rich by cutting off our feets and stealing our tonsils! I know this is a true fact because Obama told me so!
    ;-)

    • Mandy

      let’s go to the video:

      Obama: Doctors Taking Tonsils Out For Money Instead Of Diagnosing It As Allergies

      There ya go. You mean ol’ tonsil-stealing foot-chopping money-grubbing one-percenters, you!

      ;-)

      • Cris

        “The doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out.’”

        It’s depressing enough that that’s how a lot of people already think, it’s even more depressing that the popular and well-trusted President of the United States is confirming their delusions and egging them on even more.

  • Kaonwarb

    See the link below for why this message does not play with the general public. Which rectangles are darkest (i.e. highest percentage of one-percenters)?:
    http://www.nytimes.com/packages/html/newsgraphics/2012/0115-one-percent-occupations/

  • Guest

    I shared this on my FB but I wonder how many non-docs will even care. I wonder if we’ve been so vilified that at this point there’s no turning back?

  • doublj01

    Was this sent to congress? And will anyone there even care? And who would be responsible for making the first step towards a change, if at all possible?

  • Ian

    While I applaud such well written articles as this there are two primary fallacies with what is written. The first is a good 1/2 the country doesn’t care and just think that doctors golf three times a week. They don’t really care about the cost of schooling and medical liability and just want what they feel is their right for breathing in the United States (notice I didn’t say citizen). No amount of talking to them will fix this. Few seem to understand that healthcare is a commodity and the government can only control the cost via price controls. There is of course the current CMS version (DEXA reimbursement just got cut another 15% this year) to the enactment of the Independent Payment Advisory Board. Even the UK has NICE.
    The second thing being missed is that what is happening is completely by design. Doctors are being pushed into working for conglomerates or for hospitals (because of mandates, red tape, and EHR’s) where they are easier to control. When the only choice people have is the mega or regional monopoly people won’t have a choice about seeing a nurse practitioner or PA. I’m not using this as a platform for dismissing the good work and scope of practice that these providers perform. I’m just pointing out they are a lot cheaper to train and hire for a hospital or coporation than a physician (another way to price control healthcare by beancounters). This has been a natural trajectory for some time. Is anyone really surprised that after the advent of the Hospitalists that hospitals wouldn’t start branching out into outpatient primary care?

    Doctors only have a few choices left that doens’t involve working for some corporate or government taskmaster. Branch out and find an alternate source of revenue such as research (This assumes that the federal government doesn’t legislate that you must take Medicare/Medicaid to see patients and you don’t consider doing research for a pharmaceutical company as not working for a corporate taskmaster). Join the enemy and work for an insurance company whereby you can have a cushy 9-5 job and crush the hopes of your fellow physicians. Go work for pharma… never mind. Go off the grid and go concierge. Do something completly different (I know a doc who is now a full time brewer restauranter). Retire for the lucky few who were born early enough to be able to do so. I used to remember visiting the mom and pop hardware store growing up. They don’t exist anymore. The next generation will not know what it is like to have their own doctor. Aided and colluded by big insurance, big pharma, and the government the era of the independent personalized doctor who takes an individuals health into account without answering to some third party beancounter is over.

  • http://www.facebook.com/sujana.pulivarti Sujana Pulivarti

    I have been following maryland’s mental health care reform and i am truly, truly disgusted. As a lawyer, i have been displaced by outsourcing by indian lawyers(who have been trained at the worst law schools possible), and by lower educated paralegals, technology. my dad who is an excellent nephrologist who is went through 3 residencies and is triple board certified makes about 130,000. i’m not kidding. i have two advanced degrees and two certificates and have been unemployed for four years. on top of that i hate nurses and social workers who think they are better than psychiatrists and psychologists. on top of all that; i’m poor and have unipolar depression. i’m on the brink of bankruptcy and i am truly scared about who will preform the my future ect treatments. nurses are taught under a different standard of care and frankly if they want to play doctor; make them take the medical boards. those egomanics will surely fail. nurses can not practice medicine. we need to encourage medical students to enter the field and hosptials need to stop with this parity nonsense. i will personally raise the money myself. i am disgusted and dumbasses do not belong in the such a superior position.

  • bill10526

    President Obama like President Clinton can not sift out the appealing, but distorted, claptrap from their advisers.

    An example outside of the nonsense in the video involves expensive pre-K programs – head start. Since educational level correlates highly with success in life, it just makes common sense that all children should have a good shot at achievement. But it is well known that the effect of head starts wears off completely by third grade; one fellow claims by first grade. So the expense does not yield any of the benefit expected of it. The well meant program is worthless in meeting its lofty goal. But there is a pile of papers showing that the benefit lies dormant for many years then pops out to yield $7 of benefit for each dollar expended. It is similar to alternative medicine mysticism.

    Congress is just as bad. Look at the Toyota hearings.

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