Paul M. Fischer
Everyone in medicine knows that some physicians are overpaid for the services they provide and some are underpaid. The list of specialties in each category is no secret, though we don’t talk about it much. It’s part of the same ethic that teaches us not to criticize another doctor’s care.
But the sad fact is that in medicine, money is tied to prestige, power, public credibility, and medical student interest. If we don’t deal with this problem, medicine will continue to fall hopelessly into the “haves” and the “have nots,” that is, those who “own” lucrative CPTcodes and those who don’t. So the question is how did this inequity come to be and how can it be remedied?
History shows that physician pay rarely follows value, but rather aligns with power. When I was a medical student, heart caths were new and were the domain of invasive radiologists. But it wasn’t long before the cardiology socialites took on the radiologists and successfully claimed heart imaging as their own. Power and wealth followed.
About the same time, neurologists were trying to win control of brain imaging, but they lost the political battle to radiologists. Think how different neurology’s image and influence would be today if neurologists owned all those CT andMRIscans! Instead, they are stuck in work that is time-consuming, patient-centered, cognitively complex, and are forced to make a living on payments from EEGs and EMGs.
No one would suggest that general surgeons, rheumatologists, psychiatrists, or geriatricians make more money than they deserve, but it’s a fact that many of the most highly paid physicians do the least stressful and most repetitive work in medicine. The radiologist sits in a dark room all day without the stress of patient interaction, looking at pictures that, in many cases, have already been read and interpreted by clinicians who needed the results yesterday. The anesthesiologist starts IVs, monitors drips, and measures vital signs. There is an occasional emergency but most of the day-to-day work isn’t very demanding. The gastroenterologist spends his day looking at the cleansed colons of patients who are asleep. The opthamologist spends most of his time doing a single procedure over and over again.
Cardiologists are the most striking example. They have perfected the “I saved your life” routine, when the truth is that most stents are placed in patients who could have been treated equally well with $4 medicines from Walmart. The greatest improvements in heart health are a result of statins, aspirin, and smoking advice – all the domain of primary care. And then there are the dermatologists. How stressful or cognitively demanding is it to freeze keratoses?
While it’s true that we need all of these specialties, it’s time for some of them to earn less. The reason is that many other specialties deserve to be paid more. The average primary care physician, for example, makes one third of the income of the specialists above, yet research clearly shows that, of all medical specialties, primary care provides the greatest value. The more primary care in a population, the better the healthcare outcomes and the lower the overall healthcare costs. No other specialty can make this claim.
Everyone gives lip service to better payment for primary care, but the AMA and many specialists say that this should not be at the expense of other physicians. In a societyalready overburdened by the cost of medicine, physician payment is a zero-sum game. Any increase in the income to underpaid specialists will come at the expense of those who are overpaid, and this should be publicly acknowledged by anyone who purports to support primary care.
The trick, then, is to figure out whose income should go up, whose should go down, and how to politically influence CPT and ICD coding – the language of physician payment – in a way that promotes better, more affordable medicine for America. The historical lesson from the past 20 years is this: the specialties that prosper are those that have positioned themselves to be defined by a few well-paid, narrowly defined, tightly held codes. The medical societies that fight for and defend their specialty’s codes will win. At the other extreme are the specialties that rely on vague, poorly paid, and widely used codes (think E/M). They have no chance. The medical societies that believe this engagement is “fair” are like boy scouts in the middle of a mob turf war.
It is hard to be a physician who spends all day caring for patients who are worried, angry, afraid, depressed, hurting, or dying. It is hard to spend all day cognitively sorting through limitless diagnoses based on the myriad complaints patients present to their doctor. It is often hard to know whether a patient is best treated with a few words of reassurance or if high-tech medical care is needed. And it is really hard to do all of this knowing that, in the payment game, the field is not level and the rules are rigged.
Paul Fischer, MD is a family physician in Augusta, GA. With 5 colleagues, he recently filed suit in federal court against CMS, claiming that agency’s longstanding relationship with the AMA’s RUC, the advisory group whose recommendations have resulted in the current physician payment structure, has broken the law by not requiring the RUC to adhere to the Federal Advisory Committee Act’s management and reporting rules.
Care And Cost 
This article is spot on. Turf is king and the well-situated ologists are depriving primary care medicine of the pay they deserve and the care we so desperately need – it’s classic dog-in-the-manger. That is good for the well-placed docs, but bad for everyone else in the food chain.
Nice article but the issues should not be between physicians of different specialties.
The issues are between physicians in general and the power of the government sponsored and endorsed third party payment scheme that puts patients in the middle.
Let patients decide what physician care is worth, instead of the artificial political power games played by government, RVU’s, insurers, etc…
If you state that the power is in the hands of the politically connected, the only way to solve the problem is to get it away from politics, which means directly in the hands of the consumer.
There are many cash and concierge practices that have started over the past few years. Some are expensive, some are very affordable.These practices for the most part bypass the political system and provide excellent care.
So instead of stating that we don’t have a seat at the table, why not just remove the table??
Sorry Dr SH, but I can’t agree. The problem from a pure economics perspective lies in the reality that we have an unbridled fee-for-all problem. You say let patients decide what physicians are worth? Are you kidding? Patients need to be able to place their trust and confidence in the guidance of their cognitive-driven (vs proceduralist-driven) physicians who will do the right things at the right time at the right costs that will manage and reduce the rudderless waste and inefficiencies that will drive us into the poorhouse. As Christensen at Harvard has written, we need to disrupt the system big time. We need to take the runaway freight train of medical costs a thorough disruptive tuneup and then put it back on the tracks much leaner and meaner through evidence-based, common sense deliveries of health care. We can’t keep our current system – acknowledge that and prepare for the future. Either it gets fixed by people empowered to fix it, or the black hole out there will mandate a draconian future for all of medicine and all who practice medicine. The time for turf issues is rapidly drawing to a close, and doctors need to seek a professional equilibrium – or have it shoved down their throats. Just look at what is coming your way via the Patient Centered Outcomes Research Institute (PCORI). If you want a summary, go to my website and see my see my blog – PCORI, The Dreaded Onrushing Train.
I appreciate the effort but at this point we should just leave the proceduralists to fight it out with the third party payers and market ourselves directly to patients.
Fixing the RUC was the right thing to do ten years ago, now we just need to get out.
Sorry you disagree chris, but the more government and third party get involved in care, the more costly it gets, and the less efficiencies develop. It is basic economics that when a middleman gets involved, costs go up, as they are taking a piece of the pie.
There is no fee for all problem. Fees are already fixed by insurance contracts and Medicare. Where has that gotten us?
Move insurance back to what it was meant to be, Insurance.
Stop ignoring the fact that insurers are not that, but they are health plans that seek to limit costs.
The one area I may agree is the direction of the present system is not sustainable. But that is due to the use of using other peoples money for care, and the entitlement mantra that it creates in patients. We need a switch back to true fee for service, outside of third party control. Leave the decisions to the two parties involved, the patient and the doctor.
You want leaner, so do I. But not by force or government edict. Let docs and hospitals truly compete. What you will see is the same thing that has happened with Walmart generic prescriptions for $4, and LAsik procedures where the prices are a fraction of where they started, as competition was allowed to work its magic.
Get the govt and other middlemen out of healthcare payment. If govt needs to be involved, let them give a yearly HSA stipend to the needy along with a catstrophic policy for the needy and others. But stay out of the day to day mismanagement that has created the system that I have been a part of for 20 years.
“No one would suggest that general surgeons, rheumatologists, psychiatrists, or geriatricians make more money than they deserve, but it’s a fact that many of the most highly paid physicians do the least stressful and most repetitive work in medicine.”
Can you cite some credible, peer reviewed references. I am interested in following up any links you can provide.
Thanks
Brad
Dr SH, there truly is no way we should sanely advocate for third-part intrusion into health care. These just muck up health care. It’s visible – it’s palpable and wasteful.
Government? Have you seen the mind-boggling array of bureaucratic pigeon holes that will be spawned by ACA? Do you fully comprehend the fact that the wheel to OUR nation’s financial bus has just been handed over to 12 partisan politicians (the super committee) who will catapult us into a preordained failure-to-commit default following the senseless political comedy about our debt ceiling – all because they can’t agree on anything but party lines? Do you realize that the PCORI (the nice new term for comparative effectiveness research) is made up of 19 people who will be influential, in concert with the Secretary of the U.S. Department of Health and Human Services, in pursuing coverage decisions for more than 300 million Americans? Make no mistake about it – that’s working in favor of government, not physicians and patients. How many more new ICD-10 codes will there be in two years? From 17,000 now to 155,000 (according to one estimate I read). Wow!
That said, exactly where do we turn for sanity and directions that will put health care back on the right track? It has to be a free-market initiative – my own personal view is that the nation’s businesses who pay for health care should step up to the plate big time and take the proverbial bull by the horns. Some have.
But you say there is no fee-for-all problem. How can you say that when the spending we do is judged so horribly inefficient and wasteful because of this ceaseless profusion of over-utilization, over-diagnosis, over-prescribing and over-treatment? You say that fees are already fixed by insurance contracts and Medicare – where has that gotten us? Those fees may be fixed under ICDs, but what has prevented the mass profusion of demonstrably overdone numbers of diagnoses, treatments, procedures and prescriptions? It’s almost Pavlovian – just keep pushing the “done” button and the fee-for-service mill keeps grinding out precious, dwindling health care dollars.
You say move insurance back to what it was meant to be – insurance. And just let them keep paying our dwindling health care dollars without some semblance of control over our spending? That’s no solution without master controls on our out of control cost-generating health spending.
You say leave the decisions to the two parties involved, the patient and the doctor. Yes, just as soon as we have revitalized a lot of doctoring to ensure that doctors are not overutilizing, over-diagnosing, over-treating and over-prescribing, and that patients are no longer getting what they want simply because they demand it. If there are outside factors mandating any of the excesses (as some say medical malpractice does) – then let’s attack the outside catalysts to higher costs. Let’s steamroll them under and clear the way for medicine absent undue costly influences.
You say you want leaner, so let docs and hospitals truly compete. My question is how? Let docs and hospitals truly compete – just like they are doing in Dallas/Ft Worth, where the two big systems are waging a turf war by sucking up all the docs they can into their feeder mechanism? Let’s just see what two giant ACOs can accomplish – if we ever see one of those unicorns.
If I somehow (LOL) come off as passionate about these views, it’s motivated by a lot of very, very good docs I have known for years (almost all primary care) – who have been increasingly staggered by the load of more government, more regulations, more paperwork, less pay, less respect and longer days – all compounded by this growing sense of deprivation from doing what it is they love doing most and the reason they became physicians. So yeah, I’m pretty passionate about this.
Chris
Chris
We probably agree on much, just not how to get there.
The problem with the skyrocketing of costs began with the third party system and the corporatization of healthcare. Until individuals are held responsible for their health, instead of the taxpayer, costs will continue to go up.
What we want is less government money in the system, so the taxpayer doesn’t get hit. That will not occur with ACO’s which I despise, nor with any managed care system.
If you truly want the system to work, it needs to be from the ground up, with patients choosing their docs, and the docs only concern being their care. Docs can offer testing and treatments, but the patient should always have the authority to say yeah or nay! Just as if you are going to buy a car, and deciding on extras. You get to choose, other than the standard features.
Businesses can help pay for healthcare, but by giving catastrophic insurance along with some HSA money. Then they should stay away and leave care between the doctor and the patient. Get the mismanaged care organizations out of healthcare.
Waste comes from the mismanaged care organizations as a result of their bureaucracy. Every layer adds to costs all thru the system, but they don’t care because whoever holds the purse has all the power.
Overdone procedures will slowly become a thing of the past if people have their own skin in the game. Presently docs answer more to their office managers, administrators, employers, and government regulators than to their patients. Who set up those rules? The answer is govt and insurer collusion.
What should you care what your neighbor spends on healthcare if they are spending their own money? In a free market system people spend their own money.
We agree on getting rid of undue influences in medicine. That would save a tremendous amount of money. But again the biggest influence is the third party system set in place by government collusion. Why do you think the insurers backed Obamacare?
With an open free market the Dallas area would be awash with physician entrepreneurs developing newer and better care at cheaper costs. It happens wherever it has tried. Look again at the cost drop of LASIK and generic drugs. It works if it is allowed to.
I am a solo family practice doc working almost totally outside the system. I am not only passionate about this subject, I live it every day and I also practice what I preach.
Dr SH
You are most definitely right, we probably agree on much. Just on principle I’d readily agree to that because you are one of the front-line soldiers in this system. Because of the negative trends, we’re running out of the most valuable infantry against escalating costs and that is all wrong. In this battle, the people I enjoy knowing and collaborating with most in my efforts are primary care docs. I see it and experience the challenges through them, as I work with them to help look ahead to the future events that will impact them directly. The headwinds you and your primary care colleagues are facing are stiff.
That does not mean I am an enemy of specialists. I am an enemy of going broke on too much of good things.
On personal responsibility, you are spot on. I could just pound a table every time I see a fat little kid eating something nasty, or someone with globs of fat hanging over their belts. I also want to put a fist through the wall every time I see a pharma ad encouraging patients to go piss off their docs with requests for this or that.
Yes we definitely want less government money in the system, because it’s all funny-money anyhow. YES – I also hate ACOs because they’re fad, boutique concepts that hospital systems in Dallas are using to corner turf.
Maybe we don’t agree on all perspectives to the solutions, but I do agree with you that we need to effect change from the foundation up. That foundation needs to be primary care docs who form true doctor-patient relationships with their patients as whole persons – and who have the time to treat the spectrum of whole person issues that constitutes total patient care – cost-effective care that understands what to and what not to do. No way does that include me telling my doc I need an MRI. If I go in to see my doc to manage the whole me, with my blood pressure management, cholesterol control, bum knee and reflux, I don’t want to walk out feeling good across the spectrum of my little maladies, while also knowing that my doc only gets paid for two of the issues she treated. Pay primary care for the cognitive work that it takes to treat whole persons.
A reason I put the burden on businesses is that businesses are holders of clout. We work, we’re at work much of our lives and businesses are a place to put the right pressures and incentives to employees. Businesses can and should create incentives for employees to be patients, to have their doctors, to form solid relationships with their doctors, and then maintain the good relationships. It sure works for me because I like my doc and she likes me. After that, it’s doctors and patients who know each other and who make the system work knowledgeably.
Skin in the game? You betcha! Money talks volumes.
Keep on Dr SH, keep on!
Your mom is eatxcly the type of person needed to participate in the debate. I hope she continues to speak out, as well all should.