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  1. I was referring to in hospital billing/defensive med. Docs who have no financial gain at ordering tests would more likely be motivated by good practise, defensive or not, but maybe they’re just poor diagnostians. If there’s no downside for the doc to order additional tests human nature would say do it. But in a for profit hospital setting when departments are held to be accountable for revenue would there be a tendancy to add a few more tests or procedures for a patient? When a hospital “invests” in an MRI isn’t there pressure to use it? Human nature would say yes. In Canada some docs found out pretty quickly that they could set up their own private test labs, then send their patients there for tests, necessary or not. Docs are the gatekeepers they determine to a very large extent how the system is used. What oversite do the insurers make to see if a doc or hospital is using their insurance more than they should be? Do insurers perform audits? You would think that in this system the insurers would cost control, I don’t think thay do. My take, from my recent experience, is that no one rely cares because costs can just be passed on. I know of one employer who asked his insurer why they were raising rates so much so fast – the answer was, “because we can”. In Canada there is an on going and painful cost control program. Strict bugets are given and audited, and hospitals are held responsible for staying within those bugets. In a system that is seeing this huge use of healthcare, from baby-boomers, overeaters, smokers, demand, whatever, cost control is vital. Why is our system broken, because no one seems to be doing any oversite.

  2. Peter, don’t be ridiculous. If I were to order something “defensively,” it is likely going to be expensive blood tests or an MRI or CT scan. Only a minority of physician practices, and very few small groups, have labs in their offices. And even fewer physicians are able to order and bill for tests like MRIs.
    Tests that are done in a hospital, only benefit the hospital, not the physician doing the ordering. See, this is one of the things that drives me crazy regarding the costs of medical care. Someone comes into my office with belly pain, and I am worried that they might have an appendicitis and order some labs and a CT scan (let’s say appropriately and for good reason), all of which turn out okay. They later get a bill for over $1,000 and they curse my name without looking to see that my part of it was $72 and the insurance company paid me $55.
    Barry, point me to the NY Times reference for the fraud articles. The thing is, insurance companies and govt payer sources have forced us to use an extremely complicated system of codes in order to report the complexity of a visit (level 1-5) and the level of reimbursement it deserves. The only thing that separates one level of coding from the next one is how much is documented. If you take a simple visit like an earache, write down in the chart only what you truly need to see, and bill it as a level 2, that’s one way of doing it. If you use your EMR and fully document the visit, you can easily, by definition, code a level 3, and that is the code that gets the most use. But, if you’d would like to get paid $50 for the 15-minute visit, and you ask one or two more questions, and document it, you could get away with coding a level 4. Now, you wouldn’t do that for someone who is self-pay, and you might not do it for a good commercial payer that pays you the $50 for a level 3 visit, but, if Medicaid has paid you $29 for a level 3, going back 5 years now, you are tempted to ask the few extra questions, and document it, and bill Medicaid a level 4 so that you get $48 for the visit. Is this fraud? Not if the documentation supports the code you used. I would say that the real fraud is the horrific reimbursement rates that Medicaid pays.
    (For all you auditers reading these messages, I should point out that I only code what my objective EMR says is appropriate and I am never influenced by a person’s payer status when it comes to the code submitted.)

  3. How much of this so called “defensive” medicine is just a need to increase billings?

  4. Here, here Barry. I strongly agree with the idea of specialized health courts. I especially like the thoughts of this organization–http://cgood.org/healthcare.html.

  5. Dr. Hinson, that was a very interesting and informative post on defensive medicine from a doctor’s perspective.
    With respect to the culture of litigation, I think it would be helpful if malpractice suits were taken out of the hands of juries, who are generally not qualfied to judge competing scientific claims and are easily swayed by emotion and sympathy for someone who had a bad medical outcome but not necessarily due to malpractice. Instead, there should be specialized health courts with judges who have built a body of knowledge in the medical field and can specialize in hearing medical litigation cases. They are more likely to weed out “junk science” and render a fairer and more objective verdict on the merits of the case.
    Regarding patients with high expectations, I think the full body MRI example is a procedure that lends itself especially well to pricing transparency. If deductibles were considerably higher and patients were more exposed to paying more of their health care costs, perhaps their expectations would become more reasonable.
    Of course, the recently passed Massachusetts legislation that will make health insurance available to poor, previously uninsured people with no deductibles or copays and no cost control mechanism moves in exactly the opposite direction.

  6. > Fixing healthcare is about more than cutting pay for
    > docs, nurses, and hospitals, which is pretty much
    > the only focus to date…
    The focus was deeper in the 1980’s but patients hated it even more than doctors did, and now it is pretty much illegal to have a deeper focus. Which some commentators here will tell you is just as well.
    > Mediocrity is believing that healthcare is good enough
    I like this very much. Dr. David Pryor of Ascension just gave a talk a couple of weeks ago to a bunch of evil managers, and asks a couple of provocative questions: How many unnecessary deaths in hospitals are acceptable? Is the IHI campaign to save 100,000 lives ambitious enough? He thinks not, and has some hard evidence it is not. In 2005, Ascension started a project to reduce mortality rates for patients not admitted for end-of-life care, with a stretch goal to achieve a 20% reduction by 2008. They’re beating this already by working to create an expectation of patient safety and by building an organization to support it.
    Their mortality stats were noticably better than average when they started their improvement efforts, which makes their drop in mortality rates truly remarkable. And it is really hard to spin mortality data — no shades of grey in this. If Dr. Tuteur wants to see see evidence that the patient experience is improved in a meaningful way by the existence of managers and consultants, she might fly to St. Louis and talk with Dr. Pryor about the 1,200 people have not died unnecessarily in the last eighteen months in the Ascension system.

  7. Barry, defensive medicine is definitely part of the picture. Hard to quantify how big a piece of the pie it is. And we have now trained a whole generation of doctors to practice defensively. It is amazing how much “CYA” is a part of the language of residency training. As such, finding a way to fix the culture of litigation we have right now will only slowly improve things. Most doctors, if you ask them during the work day how many extraneous tests were ordered will tell you none. The invisible lawyer in the exam room makes us order the tests, but the invisible insurance claims rep makes us justify the tests in our own mind. Because of this we rationalize that all of the tests we order are necessary. In the doctor’s lounge, at the end of the day, you will hear a different tune. Ask one of us then and we’re more apt to tell you about all of the CYA tests that were ordered.
    It’s not just due to the threat of being sued however. Patients have unrealistic expectations these days. It is a very common thing for someone to come in and tell me they want a full-body MRI or something because they just know that something is wrong! And it can be very difficult talking someone out of the latest test they read about online, or heard about in an email from a friend.

  8. Mediocrity is believing that healthcare is good enough; that all you have to do every day is make sure the doors are open and that no one gets upset; that more is better; that “my patients are sicker”; that continuing education is the lecture between the slopes and the hot tub; that access is just about insurance; that all doctors are about the same; that we can design clinical services without a physician leader; that a solo practioner can provide just as good of medicine as a multi-specialty group; that calling something an “Institute” or “Center” makes it special; that hospitals fight over market share instead of sharing resources to create better care for the community; or otherwise believing that we don’t need to continually seek out ways to utilize the ever increasing body of knowledge, best practices, and quality indicators to pursue excellence in medicine.
    Much of this is about incentives, but it’s equally about how medicine is organized. Why can’t we have more Mayo’s? And you’re right, even Mayo has a curve, but I guarentee that their curve is a lot further to the right than your average physician “group”. And that is my point. Why are we satisfied that more of medicine doesn’t try to be better? Why do many of us here in Americal have to travel to Rochester to get excellent care?

  9. I would like to focus on the issue of defensive medicine. Suppose I go to a doctor (either primary care or specialist) that I have been referred to by another doctor whose judgment I respect. I say, doc, you are very well respected in your field and my referring doctor says you are among the very best. I respect your knowledge, your credentials and I trust your judgment. However, I am also concerned about costs. Even though insurance is paying most of the bill, my policy has a lifetime benefit cap. So, what I really want you to do is apply your expertise, treat me as though I were a member of your own family, and you were paying the entire bill out of your own pocket. That is, no unncessary or marginally useful tests that you may be inclined to order because you are afraid of being sued. I can assure you that I will not sue except under the most egregious circumstances (like removing the wrong lung, for example).
    It seems that many doctors are so ready for this question that they say they would still order all of the tests that they order when consciously practicing defensive medicine. However, if I met the same doctor at a conference or socially and was not a patient and asked what he or she really thought about the issue, I would probably get a different answer.
    So my question for the doctors and other professionals on the blog is: how much of the “waste motion” and how much of the total health care bill is really defensive medicine that would not be practiced if the perceived probability of being sued were near zero?

  10. I just found the blog a bit later .Wish could participate early on.
    No one can afford to ignore Mayo, if I meant that and not everyone has the potential to become like mayo that is my point. Even with in Mayo not every physician is equal, illustrating a kind of Bell Curve of its own. Respecting all the qualities, all far right hand of the curve, we know about Mayo that you enumerate, could well serve a model for other institutions.
    Too much activity what you see in health care as a ‘pursuit of mediocrity’, wouldn’t be there if those are appropriately incentivized. That is what administration is all about. Even the CEOs who can’t show results have to bite the bullet and get the bonus for achievement. The carrot has to be sweeter and the stick stronger. Even how finely it is enshrined in medical ethics, what red blooded people think in terms of excellence is in dollars and Cents. Anyway when you said about the mediocrity how did you quantify that? What is your standard of mediocrity?

  11. I realize this thread is getting old, but I just can’t let this go by. While I am a believer in the bell curve, to say that you can’t change or move the curve within any particular setting or group is, well just not correct. An “not withstanding Mayo…” – well THAT IS THE WHOLE POINT – you can’t ignore them. The reason they are better than average is because they create an environment where excellence can be pursued. They move the curve to the right within their setting. The way they are organized supports quality, continous improvement and the pursuit of excellence. I have seen too much activity in healthcare that is about the constant pursuit of mediocrity – and fighting anything that looks like improvement. The mantra of many is “change is great – as long as it doesn’t involve me”. We need to pay more attention to how medicine is organized – how it is organized to achieve excellence. Yes you can say there is a bell curve, but you can also work to move the curve to the right.

  12. Any bell curve suggests that the most excellent and most lousy physicians will lie at the extreme ends and the average will populate the middle .Not withstanding some Mayo or Cleaveland clinic the whole mass of physicans will be just average, whatever you try. they can’t be excellent because the excellent cant improver his/her perfection. This applies to any sphere of life and so its here. In a HMO system the whole idea of administrators cutting the cost is a hoax.They simply can’t if they do will be at a terible price what they cant’t measure in Dollers and Cents. Health care policy changes from time to time and it takes time to see the woes , which presently is in full swing. And a policy changes many a times by some misbegoten knee-jerk reaction.Not all the time it is well-thouught We don’t know whether the pendulum is going to swing back to the free for service( wish it were here) or head towards a universal coverage(most probable). But it will bring it’s own imperfection and we all be blogging and complaining ,and Mathew will be still here. I heard the animosity of Doctors and Managers in NHS has reached umprecedented level. A system which so long was thriving on the unpaid hours of consultant’s work , started to have deficit after it revised it’s payscale to pay them properly .Now Govt is on at Managers to become more efficient and stop squandering taxpayers money.

  13. If I may be so bold, I’d like to mention my book, just now available, about internship and residency at UCSF in the 1970s. I think it gives a good picture of what one goes through to become a surgeon; and it contains some speculation about then vs now in terms of work hours, etc. Even though it’s meant to entertain and enlighten, it seems relevant to the discussion in this thread. The book is called “Cutting Remarks; insights and recollections of a surgeon” and is available at amazon, among other places. Comparing surgery and strawberries, while a nice talking point, may not lead to the best analysis. Fixing healthcare is about more than cutting pay for docs, nurses, and hospitals, which is pretty much the only focus to date…

  14. “Administrators are responsible for much of what is wrong with healthcare” – that is the title of Dr. Tuteur’s latest posting over at her blog. Wow. How can you act so defensive on the one hand here at an imagined slight, and then go make such broad sweeping generalizations about an even broader group. I think an “administrator” must have kicked your dog when you were a child or something.
    You can’t have it both ways – where doctors are responsible for everything good in healthcare and administrators are responsible for all that is bad. If you really want to know who’s responsible just ask a nurse – they’ll tell you whose at fault… 😉

  15. Physicians and administrators can argue back and forth, but the most meaningful parameters are those that involve the patients.
    I would submit that over the last 20 years of healthcare “management”, the patient experience has deteriorated in every way:
    1. The cost of healthcare has not gone down as promised, it has gone up, both in terms of insurance costs and co-pays.
    2. The administrative hassle to patients has risen dramatically as insurance companies arbitrarily refuse to cover various items. Spent any time on the phone with an insurance company lately? It’s a nightmare.
    3. The doctor-patient relationship has been irreparably harmed by the inability to maintain a lifelong relationship with a provider, and the inability of the doctor to offer enough time to the patient.
    4. “Evidence” based medicine has failed to affect the quality of care. Bad doctors don’t need better algorithms, they need better judgement. All the algorithms in the world will not help if the physician can’t make the right diagnosis.
    5. The fate of the uninsured is worse in every way imaginable. There is less money for free care, there are more uninsured and the opportunity for many average Americans to obtain health insurance from an employer has declined.
    6. Been in a hospital lately? The wheels are coming off of hospital based care. There are not enough nurses to properly care for patients and the ones that are working are compromised by excessive patient loads. On top of that, they send you home “sicker and quicker”.
    I could go on and on, but you probably get the point by now. Administrators can chortle that doctors waste time and that adminstrators can control this supposed waste, but the central fact is that administration of healthcare is a complete failure. NONE of the central goals of cost cutting, improved medical care and improved access to care have been achieved.
    The fact is that doctors are still taking care of patients and providing value. Administrators are doing neither. If you are still focused on “waste motion”, you might consider cutting out healthcare administrators, managers and consultants. I have yet to see any evidence that the patient experience is improved in any meaningful way by their existence.

  16. > I firmly believe that you cannot do anything worth
    > doing in healthcare without physician leadership.
    Amen! Preach it Brother!
    One problem with physician leadership is that it doesn’t pay. If you think the cognitive specialties are underpaid, you ain’t seen nothin’ until you see the “specialty” to which no RVUs are assigned.
    Another problem is that leadership requires followers. I have personally seen very fine docs called “sellouts” because they dare to challenge the decisions of other doctors. I have seen them accused of Ivory Towerism when they point out that practice variation is based mostly in habit, not in any defensible medical principle. I have seen healthcare administrators, consultants, and bloggers called clueless and hateful when they point out what has been pointed out by the Ivory Tower Sellouts.
    I know surgeons tend to be very confident people, but I had niavely thought this came from years of training, and from having mastered the styles of The Greats. While observing a surgery, I overheard a conversation between two Fellows, in which one was saying to the other he couldn’t wait to get out from under the thumb of his teachers so he could “develop his own style” as if he has something truly unique and better to offer at the stage of his career when he couldn’t get an IMA loose from a chest wall in 45 minutes. Now, it seems to me the supreme confidence might simply be pure hubris. I can’t help but think this extends, perhaps in less extreme form, to other areas of medicine.
    Physician Leadership will become possible the day Professional Autonomy makes room for it. And this is under the control of The Guild.

  17. Dealing with maladaptive patient behavior is certainly part of the problem and, as such, the pursuit of medical excellence should include policies and practices focused on educating patients about proper healthcare and motivating them to comply with the prevention and maintenance regimens prescribed by their providers. I realize this isn’t easy.
    The problem of the knowledge void has to be addressed, however, so that providers have the knowledge needed to deliver the most cost-effective plans of care to all patients that are personalized based on each patient’s unique set of needs. I realize this isn’t easy either.
    But if the healthcare industry focused much more on gaining and using this knowledge, I believe the issue of defensive medicine and lawsuits would become a non-issue, we’d have a healthier population, and costs would decline. This is all part of a consumer-centric wellness model and quality through knowledge strategy.

  18. What a great comment thread!
    Physicians feeling that Matthew has maligned them some how are demonstrating one of the fundamental beliefs of many in healthcare: That all doctors are created equal. We have a joke about what you call the guy who finishes last in his med school class – “doctor”. There are clearly physicians out there who are better than others. Matthew is not pointing fingers at any specific doctor, he’s just pointing out that in the aggregate there tends to be a lot of medicine practiced that is less than effective or effecient. As one of those “consultants and administrators” I believe I am often percieved as “hating doctors”. Nothing could be further from the truth. I have great respect for doctors (and I suspect Matthew does too). I firmly believe that you cannot do anything worth doing in healthcare without physician leadership. What I don’t have respect for are doctors (or administrators) who are not interested in constant improvement and the pursuit of excellence in medicine. When you have physician leadership that seeks out excellence you can do great things – that’s how we got Mayo, Cleveland Clinic, Texas Heart, etc. etc. When you have no physician leadership, or comfort with the status quo, or fear of change – well that’s how you get most of medicine these days.

  19. Gosh goesh, you got it.
    Amy, I agree with Matt, and the studies that are out there, stating that there is 30% waste. I’ll give you an example. Healthy, attractive young female came in with hideous toes. Obviously a fungal infection of the toes. “What can I do about it?” Well, topical stuff doesn’t work. I have a pill that you can take for 3-4 months that will cure it 75% of the time. “Good, I want it.” OK, but it’s expensive. I’ll write it and you can see if your insurance will cover it. My nurse then spends 30 minutes on the phone with her insurance company when they call the next day. It turned out that they will pay for the medicine only if one of three tests are done to prove that it is indeed fungal. I bring her in, do the test, which costs $150 at the local lab, not to mention another office visit. It is positive, of course (hard to miss fungal nails), and then her insurance company pays for the $400/month medicine. That was “waste motion.”
    And, as goesh mentions, a HUGE portion of the waste we’re discussing is due to defensive medicine and unrealistic patient expectations. We all over-prescribe antibiotics because patients often expect, no, demand, them. “C’mon Doc, I know what ‘likely viral’ means, but I have got to get back to work and that ‘Z-pack’ knocks it out every time.” And we all over-test because of the threat of litigation.
    Reading this blog, I often think of health care reform and malpractice reform as two different topics, but maybe, for these reasons, they cannot be considered separately.

  20. I’m sure I hate doctors as much as the next person until I need one. This layman sees the threat of malpractice lawsuits as the major health care crisis. It reflects the patients unwillingness to take responsbility for their health and forces the Doctor to over-medicate and refer to specialists to cover their butts. To cover the proverbial butt, doctors need to keep seeing a patient as well. Everyone wants an instant fix and instant gratification and nobody wants to be held accountable for their own actions and DNA. How many doctors reading this have patients tell them they don’t want any medication? How many have patients coming in asking for specific medication they have seen advertised on TV? There ya’ go- one day I went around to about 20 different doctor’s offices just to see how many patients were lined up for treatment and to get an idea of their general age and appearance. Every darn office was literally filled with mostly young to middle-aged people. We have the best food and technology and pretty secure living environments, yet half the damn nation is sick! We hold Doctors responsbile for our ailments, because if they can’t instantly alleviate the pain and problems, then they are doing something wrong and the next step is litigation. How many doctors have quit telling patients to stop smoking,to cut back on the eating, to quit abusing alcohol, to get active, to get psychotherapy, simply because the patient won’t comply? The day I made my ’rounds’ examining all the doctors offices, I spent just about an hour in the parking lot of a pulminary specialist. I saw 4 people light up a cigarette upon exiting the Doctor’s office. I figured that would be the case and it was, and don’t you know some of these people went home and told their families the Doctor wasn’t doing much for them – and when their loved one dies off, some of these folks will go running to a lawyer faster than a prescription can be written.

  21. I don’t know how much time spent by providers is a waste and how much salary is fair. But there’s something about “muda” that Matt mentioned, which I find intriguing.
    It seems to boil down to this: Seek flawless perfection!
    In healthcare, that means no errors, no omissions, no overtesting, no overtreating, no overrefering, no undertesting, no undertreating, no underrefering, no misdiagnoses, delivery of only the most cost-effective evidence-based treatments to every patient based on their precise constitution and needs, motivate every patient to comply completely with valid prevention and maintenance programs, continually collect and analyze clinical outcomes data and use that information to establish and evolve evidence-based practice guidelines.
    “The point of all this is to squeeze out muda. The objective is to whittle inputs and outputs at every stage to no more than what is needed, when it’s needed, where it’s needed and only in the amount needed.”
    I love it!!!! It focuses first and foremost on patient-centered quality-improvement. Now that makes sense to me.
    I suggest that every discussion about the healthcare crisis and potential solutions be framed in the context of muda-reduction. Monetary policies should focus on how to pave the path to perfection through incentives, remunerations, and investments that enable everyone to receive optimal care. The science and technology of healthcare should focus on how to pave the path to perfection by stimulating learning, knowledge creation, innovation, and HIT development that improve diagnoses, plan of care selection, and order execution and coordination. The practice of healthcare should focus on how to pave the path to perfection by giving providers the knowledge, skills, tools, time, and other resources they need to treat and train their patients for optimal health and well-being.
    Using these anti-muda strategies and objectives to guide our policies and practices, I believe, is the only way to find sustainable solutions to the healthcare crisis in a way that benefits all stakeholders.

  22. As I understood it, your comment was not principally about physicians incomes. I understood your comment to suggest that demand for physicians is rising, notwithstanding that 30% of what they do is a complete waste of time.
    Speaking for myself, I am objecting to the notion that 1/3 of what doctors do is “waste motion” and that healthcare administrators or consultants could identify ahead of time what procedures, tests, etc. were part of the waste.
    The issue of physician income is a red herring for a variety of reasons. I don’t know where you get your statistics, but if you are trying to suggest that physician incomes have kept pace with real estate costs, or have kept pace with the salaries of similarly educated lawyers and MBAs, I’d love to see the data. The rise of physician incomes in “real terms” is a meaningless statistic.
    Furthermore, if healthcare administrators, consultants etc. have not been able to erode physician income (they call it controlling costs), they have been completely useless since that is one of their stated goals. You can’t have it both ways. Either physician income has taken a big hit, or healthcare administrators have been a big failure.
    Second, physician income is not what is driving doctors out of medicine (producing the demand that is in part responsible for the rising salaries of new doctors). It is the inability to provide quality medical care in the face of mindless and useless regulation that diverts money from patient needs into administrative salaries. Managed care has been a colossal failure. It has nothing to do with caring for anyone, it has not controlled costs and it has contributed to destroying the medical system of this country.
    Your comment may have been a joke, but it provoked strong feelings because it is based on a real perception. I suspect that many healthcare administrators, consultants, etc. actually believe 30% of what doctors do is waste and 100% of what healthcare administrators do is useful. That is galling.
    Most doctors are well aware that some of what they do is wasteful (in retrospect), but many of us feel that most of what healthcare administrators do is worse than “waste motion”. It is based on the completely erroneous premise that healthcare costs are so high because of “waste” and that administrators are capable of identifying and controlling that “waste”. Administrative efforts in “controlling costs” have been an utter failure. Perhaps less money should be spent on adminstrators and more on actually taking care of sick people.

  23. My, my, my, I was unaware that the last 40 years of medicine, during which physician incomes ang physician numbers have risen dramatically in real terms, had been such a disaster for the profession.
    Yes, of course the differential between specialist and generalist pay is a huge problem, but roughly 70% of US physicians are specialists. And yes, after the 70s and 80s in which physicians did incredibly well (physician incomes went up by 25% in real terms in the 80s) the 1990s werent so much fun. But even then incomes only went down in real terms by 5% overall. Since then (and there’s no real reliable income data–I just spent 30 minutes searching for it) overall health care costs have risen and it appears that physician incomes have too — survey data certainly shows that their satisfaction levels are back up after the angst of the 1990s. The original article referenced in this thread certainly suggests that we’re in another boom period.
    But apparently all the activities over the decades from the AMA and other organizations protecting physicians incomes, and by the by, putting a stop to wider health reform, have been a figment of my imagination. Instead, apparently in my “leftwing/redtaped/pro-beaurocracy venom” I seem to have missed that there are problems in the health care system (although some would say that that’s the only topic of this blog!).
    And, despite the fact that I think physician-led organizations a la Mayo Clinic should run our health care system and divide up all the money, and despite my consistent criticism of insurers in the last 5 years, because I made a mild jab at physicians pissing and moaning when things are getting good for them — a concept which several physicians have confirmed to be true by their comments here — it’s all my fault!
    I’m glad that I have so much influence!

  24. JD:
    Amen. The RVU system is irredeemably broken. One minor disagreement — the system is slanted not towards specialists per se, but towards proceduralists. Why is it that as an ER doc, I get paid 2-3 times as much for putting a dislocated hip back in than I do for providing an hour of critical care? The hip takes a little sweat, maybe ten minutes, no thought, and little risk. Critical care is cognitively hard, time-consuming, risky, and for much higher stakes. It’s f*cked up.
    But the specialists whose practices are cognitively-based: Neurology, infectious disease, endocrine, rheum, etc, are also underpaid. The specialists who are procedure driven like all surgeons, GI, Cardiology, are grossly overpaid. I don’t know if there is fix possible given the systemic nature of the flaws and the political reality of the RVU Update Committee.

  25. Boy oh boy Matthew you just brained by Dr Tuteur! Good going Amy! I just don’t have the time right now to respond to Mr Holt’s leftwing/redtaped/pro-beaurocracy venom but I am glad someone jumped on him. I have to get back to seeing patients.

  26. Guys please relax. Some of you are thin skinned.
    I agree with Matthew that there is waste in healthcare and that things could be run more efficiently, but thats true of ALL INDUSTRIAL SECTORS, not just medicine.
    As somebody else pointed out, which I hope Matthew understands, is that specialists and primary care doctors are two COMPLETELY DIFFERENT ANIMALS.
    The average doctor in the United States makes about 150k before taxes (see US Labor Dept for proof). That includes all doctors, from the FP making 80k per year, to the super duper plastic surgeon pulling in 800k per year.
    Specialists are extremely well paid, primary care doctors not nearly as much.
    The way doctors are paid depends mostly on the annual allocation of RVUs (relative value units) used in the Medicare plan. Most insurance companies base their reimbursement on what Medicare pays, so Medicare is essentially the de facto standard for how doctors are paid. RVUs are set from a fixed pie of money that Medicare agrees to spend every year on doctors incomes. Doctors have no control over the total amount of money paid to doctors, that comes about by a complex math formula. But what doctors DO control is how the RVUs are split up among doctors.
    Its well known that the committee who sets RVUs is disproportionately represented by specialists. They have disproportionately increased RVUs to specialists. Since its a fixed pie, that means RVUs have decreased to primary care docs.
    The RVUs need to be redistributed: away from specialists and towards primary care. Then you’ll see more medical school students pursuing primary care.
    Another thing to do is increase incentives for med students to go into primary care. The most popular method is the National Health Service Corps. However, that program is severely underfunded. ONly a small percentage of those who apply get the funding to practice primary care in an underserved area.
    I think its reasonable to expect a primary care doc to clear 100k. Matthew mentioned GM workers, but what he didnt mention is that a typical blue collar GM worker can make 100k with overtime pay. Thats 100k for a guy straight out of high school with no college or grad school. They get more benefits/perks than primary care doctors get too.
    As I said, the national average for doctors before taxes is about 150k. I think thats about right. I dont think we should expect doctors to work for wages similar to what other college grads make, who dont have nearly the debt load and dont spend nearly as long in training as doctors do.
    Specialists need to be paid less, and primary care doctors need to be paid more.

  27. This is going to help deal with the current crisis in healthcare? Let’s take a step back, way back and start again.
    You made a nasty, gratitous crack about doctors. You can’t expect that any doctor is going to accept advice about healthcare reform from someone who appears to exhibit contempt for physicians. I appreciate that a blog needs to be provocative (I have a little blog, too), but it is precisely this apparent contempt that makes physicians’ blood boil at the thought of accepting advice on healthcare “reform” from consultants who have little understanding of, or respect for doctors.
    I am not arguing that anyone needs to feel sorry for doctors or that doctors have a harder life than anyone else, since life consists of more than work. However, they do have a harder job than anyone else. It is a fact that doctors work longer hours than anyone else. It is a fact that their training is more rigorous than that of any other professional. It is a fact that doctors have more responsibility for life and death in their jobs than anyone else (excluding the military). It is a fact that doctors are legally expected to be perfect each and every day, even though we know that it is impossible for any human being to do so. If someone cannot recognize these basic truths about physicians, he or she cannot hope to understand the system.
    “No ones’s saying that internship is a luxury gig, but you have 30 years of a pretty damn good career to look forward to afterwards.”
    No, I don’t. I gave up the practice of medicine years ago because I felt that managed care made it impossible for me to reconcile my moral obligations to my patients with the incessant demands of administrators to take services away from my patients and give the money to them. I was just sick and tired of fighting with executives for what my patients needed and deserved. And I was sick and tired of disappointing my patients over and over again when I was forced to discharge them from the hospital before they were ready, or forced to limit my office appointments to 7 minutes (literally) to be more “efficient”.
    The medical system is so unbelievably broken that it is difficult for me to get my mind around it. If you don’t think it’s completely broken, then you haven’t been a patient lately. I have witnessed 20 years of health care consultants and reform and “evidence” based medicine and I have seen medical care get worse and patient dissatisfaction grow, and the worst thing about it is that no one saved any money. They just took money away from the patients and gave it to managers and administrators and consultants who make no one better and save nothing.
    The healthcare crisis is a complicated problem and there is no simple solution. However, I can tell you this: doctors don’t deserve to be insulted. It’s not their fault, they can’t fix it, and they are more upset about it than you can imagine.

  28. GH. No I’m not talking about adminstrative waste, although of course that’s part of it, and we should be getting rid of much of it as possible. What I’m talking about the inefficient processes followed somewhere between 30% and 60% of the time in medicine. See Dartmouth, IHI, etc, etc, etc for more evidence about that.
    And see Michael Millenson’s “Demanding Medical Excellence” book for how organized medicine has played the major role in hiding those inefficiencies and the medical errors they cause from public view. And I am not making this up, Look at this article about Virginia Mason in Seattle and its pursuit of rooting out “muda”. This is well known in the literature and has been for 15 years. The news just seems to not have reached certain physicians!
    I have no problem with every doctor post training making 200K a year or more (5 times average salaries seems reasonable), but the uneveness in salaries is crazy — and again casued by the payers. However you said somehting very true in an earlier comment when you said
    “Those that they do go to med school are choosing these lifestyle, high-paying specialties. (Radiology, etc) In so doing, they are creating a huge demand for the specialties needed to care for the aging population.”
    As has also been known for more than 2 decades, in a cost unconscious environment, physicians have been able to create their own demand.
    And my actual view is that we should give all the money to physician-led organizations (like Virginia Mason) and let them figure out how to spend it. I have no interest in getting into that fight at all. But I’d be very happy if Don Berwick and Jack Wennberg led the charge. I hope that Dr. Tuteur would be too.
    What amuses me is that I put out a little tease and so many doctors who should know better take the bait….

  29. Matthew, I think some are taking exception to your term “waste motion” without understanding what you meant by it. You are, I believe, referring to the extreme amount of money we waste on the administrative burden related to our healthcare system. Right? I believe Dr. Tuteur would likely agree with you there. Or at least she will once she is out of residency and has to try and get an insurance company to pay on a clean claim.
    But your disdain for doctors comes through quite clearly. And I am sorry to tell you this. But unless we all get along, there will never be significant reform of this broken system of ours.
    One other point you seem to not miss. When you think about physician income (and the steam comes out of your ears) you seem to lump us all together. There are cardiac surgeons making $500,000. Dermatologists making $400,000. Radiologists making $350,000. Yes. But there are also internists struggling to take home $90,000, pediatricians doing the same, and general surgeons working 80 hours a week to pocket $200,000.
    There is a huge discrepancy between the pay of primary care physicians and some specialists. You cannot lump us all together. Primary care as we know it is about to collapse.
    (And, though it is an above average income, if you have a problem with an internist wanting to make more than $90,000–a lot more–for all of the troubles and responsibilities that come with the job, then we are not even close to being on the same page and will doubt any reforms you champion.)

  30. Your statement “NO ONE works harder, for longer hours, for less appreciation than your average doctor” suddenly becomes “anyone who makes more money than a strawberry picker has no right to complain about their job in any way?” — that’s a teeny tiny logic jump, eh?
    No ones’s saying that internship is a luxury gig, but you have 30 years of a pretty damn good career to look forward to afterwards. And the same thing is true for junior lawyers/consultants/investment bankers et al, all of whom work damn hard and do pretty well too eventually. Not so true for plenty of other people who work damn hard such as the strawberry pickers, so I’m glad that you’ve qualified your “NO ONE” statement.
    And funnily enough all the “experts” I’ve cited are doctors who perhaps have decided to figure out why there’s “carnage” going on out there, and do something about it by trying to change the practice of medicine at a system level.
    Or you could just claim that you’re playing God and we mere mortals just don’t understand and shouldn’t be allowed to comment? Fair enough, that approach has more or less worked for the past 8,000 years.

  31. Are you suggesting that anyone who makes more money than a strawberry picker has no right to complain about their job in any way? Are you suggesting that the strawberry picker could be a doctor and is just picking strawberries instead? As it happens, I used to work 110 of 168 hours a week at an hourly wage of $5.45 and faced gender discrimination and sexual harrassment. That’s called internship.
    None of this has anything to do with the state of health care in the US. It may be cute to compare migrant workers with doctors, but it offers no perspective on meaningful issues. Doctors are not choosing between medicine and working in the fields; they are choosing between medicine and law and business and they will make rational choices based on hourly wage, lifestyle, liability issues and stress among other things. If you think that medicine does not require academically talented people and we could get by with people who are less intellectually accomplished, then say so. It’s a valid perspective and we could have a legitemate discussion about that.
    As far as waste motion is concerned, if those experts you quote were willing to take moral and legal responsibilty for their pronouncements, I’d be willing to consider them. If they are so certain, let their conscience bear the possibility of causing avoidable deaths.
    Have you ever had to countenance the thought that you could unintentionally kill someone? Probably not, and until you do, you cannot imagine what it means. As long as I have to take moral and legal responsibility, though, I’d rather trust my own judgment than that of “experts” who are free to walk away from any carnage that they cause.

  32. Amy. You make every one of my points. I may be taking “cheap shots” but so has Jack Wennberg for 35 years. And you may be right that I can’t point out what’s waste motion, but luckily Brent James, David Eddy and Elizabeth McGuinn have been doing it for me.
    And if you read the example, I’m bascially comparing your salary to that of a GM executive. Yours apparently is going up, their’s are going down–fast.
    But I’m glad to know that doctors have worked very hard to get where they are and that “NO ONE works harder, for longer hours, for less appreciation than your average doctor.” I’m also glad that you’re not pissing and moaning about your lifestyle/income. On the other hand, do you want to go pick strawberries instead?
    “The typical California strawberry worker spends as many as 12 hours a day stooped over the low berry plants. Workers report that foremen sometimes demand sexual favors from women field workers in exchange for employment. After years of loyalty, workers must line up each season to be rehired and face firings on a whim. Sometimes there is no fresh drinking water in the fields. Bathrooms are often filthy. Workers labor amid pesticides and suffer chronic back injuries, but often have little or no health insurance.California strawberry workers face these conditions for about $8,500 a season.”

  33. I’m an obstetrician, and I’d be perfectly willing to admit that a lot of what we do or what we prepare ourselves to be able to do is not needed in retrospect. I suspect that the same holds true for your 30% “waste in motion” number. I challenge you, Mr. Holt, to identify the 30% waste in advance, and to take legal responsibility for it if you choose the wrong 30%.
    A claim like yours is worse than useless if you cannot identify SPECIFICALLY each procedure, medication, test, etc. that should have been omitted. It is also a cheap shot. There is a lot that could be improved in the health care system, but I would submit that NO ONE works harder, for longer hours, for less appreciation than your average doctor. That’s why they pay doctors what they do. If anyone could or would do the job, the salary would be a lot less.
    It sounds very clever to compare a doctor’s salary to that of a GM worker, but unless you’d be happy to get your medical care from the average GM worker, you’re not entitled to make that comparison.

  34. C’mon Eric don’t be so defensive. I love doctors, even the one I’m closely related to!
    I’m just saying that 30% of health care activity is waste motion (what the Japanese call Muda)–something that is widely acknowledged! See all the Dartmouth stuff including the recent one about ICU care where the average was the use of 50-80% more physician resources for the same outcome as were used in the Mayo Clinic. And threefold use of resources in the worst offenders.
    So all health care resources should be used more efficiently, and therefore there should not be a physician shortage. But apparently there is and apparently physicians are doing OK. I’m not exactly blaming them for taking the money. I’d do the same!
    This is not the case in Detroit for GM workers.
    And France is not a classic single payer model, but that’s way off topic.

  35. This article does nothing to address the differences between the lifestyle specialities–Radiology, Dermatology, etc.–and primary care. Why is there demand for physicians? Because college students are getting smarter and realizing that there are much better ways to make moeny and have a life. Those that they do go to med school are choosing these lifestyle, high-paying specialties. In so doing, they are creating a huge demand for the specialties needed to care for the aging population.
    With the current political environment, as well as attitudes like Matthew’s, the aging boomers will have little problem finding someone to remove their back hair with a laser, or inject botox for their crow’s feet, but will have a heck of a time finding a graduate of an American medical school, or any medical school at all, to take care of their high blood pressure and aching backs.
    Eric, I completely agree with you. We need a way to incentivize the public to better take care of themselves. Health Insurance companies will never pay for preventive medicine. But doing so, will save money for the system as a whole.

  36. I understand you do not like doctors and envision a system in which all knowing and all powerful bureaucratic boards would control every facet of a physician’s life, but you never seem to apply your venom toward a public that the media regularly identifies as being overweight, out of shape, smoking, and poor eating.
    It is possible, though unlikely, that those opposed to single payer systems would be more sympathetic if those in favor even once started with the premise that the best way to manage one’s health is not the government, but personal responsibility. As mentioned so many times before, it is the only guaranteed way to improve the nation’s health and decrease healthcare spending.
    And speaking of single payer systems, I have not seen France brought up in the last couple of months– after having been previously touted as the best system in the world…