The New York Times takes a cheap shot at specialists

Most of us would agree that health care costs are too high in America.  They must be controlled or else we won’t have a sustainable health care system here.  And we should acknowledge that, on average, all doctors in America are paid higher than their overseas counterparts.  But we should also agree that expenses for doctors to earn a degree, maintain that degree and licensure, and pay their malpractice premiums is also much higher than the rest of the world.

So why has Elisabeth Rosenthal of the New York Times decided to bash specialists with her front page story entitled “Patients’ Costs Skyrocket;Specialists’ Incomes Soar”?  Perhaps the subtitle of the story explains part of the reason: “When a Doctor Becomes an Entrepreneur, Small Procedures Offer Big Returns.”

We should acknowledge that several moons have aligned that make such an article newsworthy.

First, of course, is the remarkably unaffordable Affordable Care Act.  The new law is confusing for patients (to say the least).  Not only are terms like deductibles, co-pays, subsidies, and co-insurance confusing, there is absolute uncertainty about which doctors or health care system can provide once their insurance is purchased.  Is a doctor “in-network” or “out-of-network?”  What, really, do I get for platinum, gold, silver, or bronze coverage?  How many mental health visits can a patient have with their particular policy? Because every one of the hundreds of different policies has different “rules,” patients are left to fend for themselves like never before.  Patients are confused.  Doctors, having little clue about anything regarding such care limitations and cost structure, also have little understanding about the programs sold, so they become easy targets.

Second, is the current political pressure to develop physician payment reform.  It has long been known that health care was on an unsustainable cost path.  Numerous Congressional fiats have been used to control physician costs.  There was the Medicare Volume Performance Standard (MVPS), for instance, that was later replaced by the infamous and never-enforced Medicare Sustainable Growth Rate (SGR).  Why hasn’t Congress enforced their own law?  Simple: because doctors matter to seniors worried about health care and seniors vote.  Oh, and doctors take care of Congressmen, too.  But let’s not mention this, Ms. Rosenthal — you see Americans might think their doctors are actually worth their salaries.

Third, was the stimulus package, formerly known as the American Recovery and Reinvestment Act of 2009 used to bolster the American Economy.  Within the confines of this bill were several features that laid the groundwork to the later Affordable Care Act.  These included the Health Information Technology for Economic and Clinical Health Act (HITECH Act), another 25.8 billion for information technology, $1 billion for health and wellness, $1.3 billion for comparative effectiveness research and (most important for specialists) a 40% cut to Medicare technical revenues to specialists who perform office-based procedures without a corresponding cut to similar fees paid to hospitals.  This final provision proved devastating to private specialist offices nationwide, forcing most of them to become employees of large health are systems.  The move was massive and has forever changed patients’ access to their physicians and elevated costs for them dramatically.  With such a move, doctors must now serve two masters: their employer and their patients.  All those pretty buildings, big screen TVs, administrator salaries, CEO salaries, and computer systems are very expensive.  Gee, who knew specialists’ bills would skyrocket as a result?  Yet according to Ms. Rosenthal, it’s the specialists’ fault.

But this is not the entire story.  While specialists bills have skyrocketed, their incomes have not.  I should know, because unlike Ms. Rosenthal, I am a real live US specialist and I have the W-2’s to prove it.  Again this year, another 20k less.

Why?  I believe this year’s cut was due to how I am paid.  (Because I am sworn to secrecy about such issues by my employment contract, I can’t delve into all the details, but let’s acknowledge to points: (1) productivity is important to employers since they want to get the “most bang for their buck,” and (2)  most doctor’s work is “valued” based on a Medicare metric called relative value units.)

This post is already too long to delve into details about how procedures are valued by the system, but suffice it to say, they are.  Every procedure has an RVU value.  The more you do, the more you get credit for.  This really bothers policy wonks who feel this is the single reason costs are so high in medicine.  Never is mentioned the next fact: that Medicare has a habit or “bundling” several procedure codes into one to cut costs already.  What does this mean for the doctor?  It means they earn fewer RVUs for the same work.  So doctors are spurned to do more and more to make up the difference.

Until they can’t any more.  After all, there are only so many hours in the day.

Last year my specialty had a huge change in RVU values for our expensive specialty, and because I am well-established, I have lots and lots of patients in my clinic.  Adding new ones has become nearly impossible.  But new patients means new procedures.  And without procedures, I invariably have my pay drop thanks to these hidden changes to how I am paid.

Finally, there’s the problem of Ms. Rosenthal’s salary data.  She received it from an industry-standard company that makes money reporting physician salaries to hospital systems.  They claim their data is based on physician salary surveys, but I for one can attest that I have never been asked to reveal my salary to this company.  Could they be getting their data from hospital systems instead?  Of course.

I have had the opportunity to inquire about the MGMA’s data for my subspecialty of cardiac electrophysiology.  Their data set supposedly represents only about 400 physician salaries (10%) of the entire nation’s 4000 or so electrophysiologists.  We have no idea where these data were collected.  Yet the salaries are stratisfied by RVU productivity into percentiles: 10%, 25%, 50%, 75% and 90% or better.  If you earn only a 10% RVU value, you are a dog in an employer’s eyes. If you are 90% or better, you are worshiped.

But for electrophysiology, several interesting tidbits exist: to achieve a 90% RVU value, the MGMA says that doctors must achieve over 19,000 RVUs per year as a specialist. Now I work my fanny off.  I am on call every third week.  I cover four hospitals and do plenty of procedures.  I have never made that kind of RVU productivity as shown in the 90th percentile.  Not even close.  Might this be a unachievable carrot that is being dangled before specialists’ eyes?

I was so amazed by that statistic touted by the MGMA that I asked our hospital administrative leadership to identify who the institution (or doctor) was that was producing like that.  After all, if I could learn how they are producing, I might be able to  improve my efficiencies, right?  Yet because the MGMA’s benchmarks are proprietary property, no one could identify the physician producing like that.

When brings me back to the salary figures Ms. Rosenthal quotes in her inflammatory front-page story in the New York Times.  They are non-transparent.  They are skewed and cherry-picked to make her point.  And while some salaries might be representative for some areas of the country, I suspect most are not — especially for those in competitive health care markets.  Ms. Rosenthal never mentions the regional differences in physician salaries that exist.

It seems there remains a real need to demonize physicians, especially specialists, as we proceed in health care reform.  In a system that has devalued primary care so dramatically, perhaps this is a way to gain favor for a shift in salaries to the primary care doctors.  Perhaps it’s a need to cut costs for large hospital systems that jury-rig their compensation structures on non-transparent benchmarks like the MGMA.  Whatever the reason, specialists’ salaries, jacked up my hospital systems eager to hire the most marketable talent, will remain easy targets.  After all, it’s much easier to point the finger at specialists that struggle to see all of the new patients, than to acknowledge the shortcomings of the very system that has gotten us where we are today.

Case in point: Most hospital-system CEO’s in Chicago salaries exceed many millions of dollars. Salaries and benefits of pharmaceutical and insurance companies exceed ten times that of hospital system CEOs.

But better that Ms. Rosenthal doesn’t mention these salaries or the other infrastructure changes that have gotten us where we are today.   After all, it’s much easier to take a cheap shot at specialists in the New York Times.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

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  • DoubtfulGuest

    I saw this NYT article linked in the comments to Dr. Young’s post “Balancing the physician work force” and I found it misleading. I especially cringed at the salary graphic, which looks really snazzy, and maybe unintentionally contradicts its own point. “Rich Doctors, Richer Doctors”?…Sigh…there’s a wide range, and if you take into account all the expenses (student loans and so on), some specialists aren’t making much more than PCPs, right? Why are all specialists being lumped together in these discussions? I don’t disagree with the arguments of primary care doctors here, and I can’t say I understand much about these issues. However, I’m a patient who’s needed a lot of specialist care. Most of this falls into the “cognitive specialist” realm. Aren’t these folks dealing with many of the same troubles as primary care, what with not being paid to think? On the other hand, I don’t like to see “procedures” being unilaterally criticized. I’ve also had the experience of a surgery that really helped (completely solved one problem), which made a huge difference to my ability to work and my quality of life. I don’t know what to make of any of this, except to suggest that the public should be expected to handle more nuanced information than just “PCPs v. specialists”.

  • Shirie Leng, MD

    Yes, Wes, that article was awful. Not very fair and not very balanced. As with your other readers I was surprised by her salary figures. What am I doing wrong? The fact is that as long as we treat medicine as a business there are people in the business that will find a way to make money. The rest of us will just be “rich”, apparently.

  • LeoHolmMD

    Glad to see the comments on the MGMA. I have long suspected that their data is bull. They likely get a few data points and then apply that to a bell curve. There is no physician really practicing in the 90th percentile. The MGMA works for hospitals and produces exactly what they want to see. They generate so many crooked results with their methods; it’s hard to know where to begin. Lack of transparency is the tip of the iceberg. Just as an example: if the MGMA surveys find lower salaries, by chance or whatever, then those are reported. Salaries are adjusted down, at which point, another survey is done showing lower salaries. Death spiral in a box basically.

  • whoknows

    I am sure the NYT I read was biased. And one can’t clump all specialties together. On the other hand, there are not many specialists on this site. Could be that it interests only PC.

    I am wondering if for the most part, PC is unhappy for good reasons and specialists are not or less so. Therefore they are less apt to blog and complain about medicine. It opened my eyes that maybe perhaps their specialty society lobbies more effectively for them than PC. If so, they have little reason to want to change the medical system and fight or lobby for change. They may not be as affected so much about EHR. etc.

  • Deceased MD

    Not sure about the specialists salaries, but any business minded individuals in HC, with several exceptions, are king. The fellow that owns a medical supply store making braces and prosthetics is making more than many MD’s. Anyone wanting to churn out procedures with insurance in well to do areas of the country can really profit. If your practice relies heavily on medicare, then not so, or if you work in a rural area not so. The system can really be set up to profit and exploit. Plain and simple.

  • Jason Simpson

    MGMA salary surveys are bogus. Why? Because they arent real “physician surveys.” You cant find a single doctor in the USA who actually submitted their income data to the MGMA survey.

    So where is MGMA getting this data? The answer is the practice management people for large groups. All of the CPAs who run the financial side of large physician groups report the income data of their member physicians to the MGMA. The doctors who actually belong to the groups are clueless that their leadership is doing this.

  • Bob

    The article bashes specialty physicians whose average salaries to her and any reading the story appear too high. Elisabeth Rosenthal has done many articles on cost drivers on various components of care, all true to some extent, but never one which compares areas of care with each other, on fraud. She uses an Aetna report: The Facts About Rising Health Care Costs, with a pie chart of cost in what I see as 3 equal pieces: Hospitals, prescription drugs and physicians [can't have one without the other] and “everything else”.

    In a bar graph comparing total healthcare costs in 25 top industrial nations, the U.S. shows distinctly as the highest in costs to the next highest group of mainly Scandinavian Nations, France and Canada, whose costs are 30% lower than ours. The next highest group includes the UK at around 50% lower in costs, and the lowest is Israel, 75% lower in cost than the U.S.
    In the accompanying narrative on hospital cost increases, the report lists “Waste”:
    “Wasteful spending likely accounts for between one-third and one-half of all U.S. health care spending. PricewaterhouseCoopers calculates that up to $1.2 trillion, or half of all health care spending, is the result of waste. An Institute of Medicine (IOM) report estimated unnecessary health spending totaled $750 billion in 2009 alone.” Then goes on “The biggest area of excess is defensive medicine, including redundant, inappropriate or unnecessary tests and procedures. Other factors that contribute to wasteful spending include non-adherence to medical advice and prescriptions, alcohol abuse, smoking and obesity.”
    Evidently abuse and fraud were considered small or the term “Waste” is more politically correct or socially acceptable than these two terms, so are we to believe that 30% to 50% of fraud is distributed equally between all care segments, while actual cases over the past 15 years fall mainly into hospital and prescription drug frauds in False Claims Act settlements, 80% of which are not investigated; or physicians?

    Comparing specialty doctors to the average primary care physicians on a single type of case is I believe misleading without comparisons to all. It is especially misleading in comparing to the average primary care physicians, whose pay is pushed down by low entitlement payments. If compared, for instance to pharmacists who are also doctors, they are comparable, while pharmacists don’t often count pills anymore, they have technicians do that; as nurses do for physicians, pushing patients farther away. And what are hospitals administrators paid, after all hospitals are the largest segment 30% of costs and the second largest in fraud cases after prescription drugs. Why not compare them to Wall Street, bank, and corporate CEO’s, which for if in their own practices they are CEO’s. The averages then aren’t vastly different, nor is the education or experience required or honesty ratings as high; docs, pharmacists, nurses and elementary teachers at the top.

    While I should be ecstatic that pharmaceutical fraud will rapidly decline as “pills” all become generic, the accompanying danger of having no governmental control over quality seems to be a great threat to the U.S. and I would believe the whole World, when no citizen, physician or pharmacists knows for sure if the drugs they depend on are safe and efficacious. I know that parallel trade in Pharmaceuticals has gone on in Europe for decades, buying drugs cheaply in poorer countries and repackaging them; selling them in countries whose prices are higher. Brand companies call this counterfeiting but governments like paying less than half their list prices, 50% less than ours. But Europe
    doesn’t allow repackagers to use the same drug ID’s as we do on the packages or they would be defrauded just as we were. Now the FDA on top of allowing multiple manufacturers to flood our market with cheap generics that the FDA can’t inspect properly the House Energy and Commerce Committee yesterday is asking the FDA why they are allowing them to change label information at will.
    And if you haven’t noticed the Fraud Fighters are targeting physicians and care givers for audits, thinking I guess we have too many physicians taking Medicaid and Medicare and want fewer!

  • Guest

    It comes down to procedural efficiency and referral sources. I practice in a small town and on a daily basis read the nuclear stress tests and echos for a 200 bed hospital, see an afternoon clinic full of patients and cath several patients each morning in addition to rounding with a mid-level who writes all notes on inpatients. Yes, my salary is high: 90th percentile with a 95th percentile wRVU total by MGMA. My average work week is only about 45 hours because the ducks are lined up in a row for me. My W2 will show 744k for the year. It pains the administration to pay my salary…they tell me so. I tell them it is so high because I am the only person reading the imaging studies for the hospital. My friends in cities who make half as much work many more hours running between hospitals for individual consults. Is my salary too high? Maybe. I feel privileged to have it – while it lasts.

  • Genevieve Yates

    Elisabeth Rosenthal’s New York Times article has made many doctors down here in Australia shake their heads in disbelief at the figures quoted. I accept that it was sensationalist journalism and that the situation is incredibly complex, but I still find it rather difficult to swallow figures such as >$25000 for removal of a small facial BCC. The US is certainly not the “land of the free” when it comes to health care.

    There are many factors involved I know, but not least is the trend in the US to provide specialised care for conditions that are competently and cost-effectively dealt with in primary care in Australia.

    The article gives examples such as a five minute consult conducted by a dermatologist, during which liquid nitrogen was applied to a wart, costing the patient $500. In Australia, (if bulk billed by a GP) it would have cost the patient nothing and the taxpayer $16.60 (slightly higher if the patient was a pensioner).

    It describes a benign mole shaved off by a nurse practitioner (with a scalpel, no stitches) costing the patient $914.56. In Australia, it could be done for under $50.

    The most staggering example of all was the description of the treatment of a small facial Basal Cell Carcinoma (BCC) which cost over $25000. In Australia, it would probably have cost the taxpayer less than $200 for its removal (depending on exact size, location and method of closure) and the patient would be out pocket maybe $25 – $100 (depending on which clinic she attended). The patient interviewed for the article was sent for Mohs surgery (and claims she was not given a choice in the matter).

    Mohs (pronounced “Moe’s” as in Moe’s Tavern from The Simpsons) is a highly effective technique for treating skin cancer and minimises the loss of non-cancerous tissue (in traditional skin cancer surgery you deliberately remove some of the surrounding normal skin to ensure you’ve excised all of the cancerous cells) This can be of great benefit in a small minority of cancers. However, this super-specialised technique is very expensive and time/ labour intensive. “Moh’s for everything” seems to be the new catch cry when it comes to skin cancer treatment in the US.

    In the past two years, working part time in skin cancer medicine in Australia, I have diagnosed literally hundreds of BCCs (Basal Cell Carcinomas). The vast majority of these I successfully treated (ie cured) in our practice without needing any specialist help. A handful were referred to general or plastic surgeons and one, only one, was referred for Mohs surgery. The nearest Mohs surgeon being 200 kilometres away from our clinic may have something to do with the low referral rate, but the fact remains, most BCCs (facial or otherwise), can be cured and have a good cosmetic outcome, without the need for Mohs surgery.

    To my mind, using Mohs on garden variety BCCs is like employing a team of chefs to come into your kitchen each morning to place bread in your toaster and then butter it for you. Overkill.

    Being the skin cancer capital of the world is perhaps not a title of which Australians should be proud, but the way we can treat them effectively, without breaking the bank, should be.

  • betsynicoletti

    The MGMA data is survey data, and when you look at each metric, it tells you the number of responses it has. For some, there may be 500 or 1000 responses. But, for some specialties, it has a count of 10. Sparse. I always want to see the number of respondents for any section.
    MGMA is a group of administrators and managers, but it’s last two CEOs are physicians.
    What struck me when I read this article was that the practice didn’t talk to the patient ahead of time about fees. It was a scheduled procedure. Many surgical practices have a surgery coordinator who sits down with the patient ahead of time, calls the insurance company or looks on line, estimates the patient due amount and collects a deposit. The practice discusses how and when the patient will pay any balance. I don’t know if the fact that it was MOHs makes that more difficult.

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