More and more doctors are fed up with private insurers. It’s not just a question of how stingy they are, but how difficult it is to get reimbursed. Paperwork, phone calls, insurers who play games by deliberately making reimbursement forms difficult to interpret…
Some physicians have just said “no” to insurers.
What does this mean for patients? Business models vary. Some doctors charge by the minute. I recently read about a physician who punches a time-clock when the appointment begins. She has calculated that her time is worth $2 per minute. Fifty-nine minutes = $118. Will you be paying cash, or by charge today?
Somehow, I think the meter would make me nervous. I suspect I might begin talking very quickly. But this is only one model.
Rather than charging by the minute, some doctors charge fee-for-service. In those cases, many physicians mark up their fees well beyond what an insurer would pay. But, they point out, they also spend more time with their patients. No one feels rushed.
A story in a New Jersey newspaper describes how physicians in Northern Jersey have begun following in the footsteps of “elite Manhattan doctors and are withdrawing from all insurance plans.” The article compares fees with and without insurance. On the right, the fees that insurers typically pay for these services; on the left, the fees that Jersey doctors who don’t take insurance charge:
- Mastectomy: $5,000 / $900Ruptured abdominal aneurysm: $8,000 / $1,800
- Routine screening mammogram: $350 / $100
- Initial neurological consultation: $400 / $100
Some Doctors Share Savings with Patients
Other physicians find that if they don’t take insurance, they can cut their overhead, and actually charge patients less.
Over at Revolution Health “Dr. Val and the Voice of Reason” tells how Dr. Alan Dappen has set up his practice:
“He is available to his patients 24 hours a day, 7 days a week, by phone, email and in person. Visits may be scheduled on the same day if needed, prescriptions may be refilled any time without an office visit, he makes house calls, and all records are kept private and digital on a hard drive in his office.”
“How much do you think this costs? Would you believe only about $300/year?”
Dappen has stream-lined his practice. It’s not just that he doesn’t need an assistant to keep up with stacks of insurance paper work. In general, he keeps his overhead low, offers full price transparency, has “physician extenders” who work with him, and “charges people for his time, not for a complex menu of tests and procedures.”
The key is that Dappen practices very conservative medicine.
“I believe in doing what is necessary and not doing what is not necessary,” he says. “The healthcare system is broken because it has perverse incentives, complicated reimbursement strategies, and cuts the patient out of the billing process. When patients don’t care what something costs, and believe that everything should be free, doctors will charge as much as they can. Third party payers use medical records to deny coverage to patients, collectively bargain for lower reimbursement, and set arbitrary fees that reward tests and procedures. This creates a bizarre positive feedback loop that results in a feeding frenzy of billing and unnecessary charges, tests, and procedures. Unlike any other sector, more competition actually drives up costs.”
Dappen has it right about competition in the healthcare marketplace. Studies show that in areas where there are more hospitals competing with each other, hospital bills are higher. This is in a part because hospitals jousting for market share all invest the same cutting-edge equipment. The only way to pay for it is to use it. So they do more tests and more procedures, driving hospital bills higher.
Dappen, who practices in Fairfax Virginia, told Dr. Val Jones that “after building a successful traditional family medicine practice he felt morally compelled to cease accepting insurance so that he could be free to practice good medicine without having to figure out how to get paid for it. He noticed that at least 50% of office visits were not necessary—and issues could be handled by phone in those cases. Phone interviews, of course, were not reimbursable by insurance.”
Dappen also casts a skeptical eye on the pricey annual physical: “The physical exam is a straw man for reimbursement. Doctors require people to appear in person at their offices so that they can bill for the time spent caring for them. But for longstanding adult patients, the physical exam rarely changes medical management of their condition. It simply allows physicians to be reimbursed for their time.”
Again, Dappen is spot on, as Niko reported on HealthBeat here.
“Cutting the middle man (health insurance) out of the equation allows me to give patients what they need without wasting their time in unnecessary in-person visits,” Dappen explains. “This also frees up my schedule so that I can spend more time with those who really do need an in-person visit.”
How many readers have found themselves sitting in a doctor’s waiting room, not because they were sick, but because they needed to renew a prescription? Since insurers don’t pay doctors for the time it takes to read an e-mail or to take a phone call and then write a new prescription, many insist that patients come in whenever they need a renewal—that way, the doctor can bill the insurer. This makes sense if the doctor needs to check your blood pressure to see whether the medication is working. But if he’s simply going to chat for a few minutes and write the script, the visit is a waste of time.
“Health insurance is certainly necessary to guard against financially catastrophic illness. And the poor need a safety net beyond what Dr. Dappen can provide” Johnson observes. “But for routine care,” a practice like Dappen’s “can make heathcare affordable to the middle class, and reduces costs by at least 50% while dramatically increasing convenience.”
Concierge Medicine
Dr. Val calls Dappen’s practice “concierge medicine for the masses.” Other physicians practice more traditional “concierge medicine”: customized, round-the-clock care for the elite.
In California, the Ventura County Star reports that local doctors opting out of insurance “spend more time with patients—and make more money.”
Some doctors charge payments an annual “membership fee”—rather like the fee you might pay to belong to a country club.
“I wish I had done it a long time ago,” says Dr. Edward Portnoy. An internist, Portnoy once had a practice of about 2,800 patients. Now he sees roughly 380 people but takes home “about the same profit” thanks to the $1,800 membership fee that each patient pays yearly.
Portnoy spends roughly twice as much time with each patient as he did when he accepted insurance. He explains that he “has more time to do intensive physicals and help patients stay healthy, rather than running from one crisis to the next like a war surgeon doing meatball surgery.”
At Dr. Stanley Frochtzwajg’s family practice in Ventura, patients don’t face annual fees but pay “at the office for whatever services they receive,” the paper observes. “A routine office visit is about $80.” Patients are then given the paperwork to submit to their insurance companies themselves. “One patient said she ends up paying about 30 percent of the bill but is happy with her care and willing to pay for it.”
The paper reports that doctors “don’t really like the term ‘concierge’ or ‘boutique’ medicine. They prefer labels like personalized, preventive care.”
That’s understandable; they don’t want to sound snobbish. But in truth: “There’s not a lot of people who can afford it,” says Anthony Wright, executive director of the consumer advocacy group Health Access California. “The reason some people call it boutique medicine is that this is for a well-to-do clientele.”
Wright is concerned: “I don’t think systems that shift more burden onto the patients are the answer to our broken system or will evolve into more than an isolated alternative…The trend of boutique medicine sends the consumers in the direction of you’re on your own. Everyone for themselves.”
On the other hand, the paper notes, “Carol Miller of Thousand Oaks thinks the $3,600 she and her husband pay in annual fees to see Portnoy is worth it because it brings peace of mind. The money covers an annual physical and a battery of screenings for everything from Alzheimer’s to sleep apnea. The fee also covers follow-up that focuses on preventive care.
“There are other perks. People in Portnoy’s waiting room find a basket filled with Cliff bars, crunchy peanut butter and chocolate chip bars. Tea and Snapple is served.
Crunchy peanut butter and chocolate bars? Is this part of the emphasis on preventive care?
Some worry about what the larger trend means. Are the Millers, who receive an annual “battery of screenings” being overtreated? If insurers reimburse for even 70 percent of unnecessary treatment, are we all paying for boutique medicine?
Dr. Bob Gonzalez, medical director at Ventura County Medical Center, also talked to the reporter and confided that he worries “that less reliance on insurance means fewer people getting healthcare. They won’t be able to afford it.
“The specter of more doctors downsizing their practices and seeing fewer patients also alarms Gonzalez. It means patients won’t be able to find any doctors or could be dumped on an already overburdened doctor.
“So yes, he said, more money, less insurance and more time with patients may be good for individual doctors.
“But whether it’s good for society or good for patients is the overall question.”
Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much, an examination of the economic forces driving the healthcare system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite healthcare reads, where this piece first appeared.
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How can I find a physician that does not accept obamacare? I have short term medical and usually pay for most of my medical care and would rather find a doctor who offers reseanable prices. Forgot to mention that I live in the Charlotte area.
Add up the amounts spent on monthly premiums PLUS the out of pocket costs to reach an insurance policy deductible.
Now add up the costs for preventive services that insurance plans do not cover (ACA has not provided these kinds of services … those that physicians who practice functional medicine rather than pharma-drive medicine)
Then, factor in the fact that most plans are going to high deductibles. That means the reimbursement rates set by the insurance company and the physicians are now the responsibility of the patient, up until those deductibles are met.
It makes no sense to say that “concierge” is elitist when anyone who is seeking basic healthcare is paying out the nose in the insurance-based healthcare paradigm.
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G. Keith Smith, M.D.
Oklahoma City
Some wonderful insights here. Great job and perhaps when I have more time, I will come back and read some more of your post.Thanks for sharing this information.
candida
First, look at your pay stub. What are you (and your employer) paying for insurance? Imagine if you paid only for catastrophic coverage and prescription coverage. Odds are, that cost would go down. For the average healthy adult, you may see the doctor once or twice a year. Imagine if your yearly healthcare costs were only the couple hundred dollars you paid to the doctor, plus your low premium catastrophic. This system would work very well for the average, healthy adult. If that saved money from regular insurance was put back into your paycheck, paying the doc $200 once a month would be a snap.
In the case of non-healthy patients, my system has obvious flaws. In those cases, more traditional insurances would still be needed, however with some common sense safeguards against the obnoxious pre-existing symptom clauses.
Not trying to argue with anyone, but if I could pay the catastrophic coverage only, my husband’s check would go up $800 a month (just for me!), and that $800 “raise” would cover all of my typical office visits, and you could even throw in some MRIs for good measure! This only works when the doctors offices have lower overhead due to less insurance/middleman madness, and pass those savings on to you. If I am fortunate and go a whole year with no doctors appointments, imagine what my family could do with that extra $800 a month!
Quite a few posters here have said “Do away with insurance companies” is the way to go. Put me down for that. I, too, think health care will benefit many times from the removal of all insurance from the planet. Lawyers and Realtors too for that matter!
Everyone in my family has diabetes. One of the things I learned from my doctor and other family members is prevention. I know prevention is only a part of it but it is an important part of health. Studies has shown that a person who is in good shape and someone who Insurance Medical are in a better position than most people to take care of themselves. Prevention is the key in my opinion. I have had back pain for years. Finally, I decided to talk to my doctor about my problem. He informed me that the body is like a machine that needs the right amount of water and fuel in order to run correctly.
The recent debate around how to best control health insurance and the cost, has pushed the issue of prevention to the front. Why is prevention so important? Everyone is complaining about the cost but the cost would not be as high if everyone took the time to properly take care of themselves. I know prevention is only a part of it but it is an important part of health. It is important because the average person is overweight and running up the medial cost. If you look at the generations before us they were in much better shape and took care of themselves. Studies has shown that a person who is in good shape and has Medical Insurance does not cost the government a lot of money. For those who do not cost the government more. I ask is the government our brother’s keeper.
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To Med Student #2,
If Young and Energetic doctors like yourself make such choices, I think most problems associated with cost of health care would go away.
Why do the specialist doctors charges $300 or $400 per patient visit? (in order to make millions)
Well, there are several reasons-
i) first of all looks like, somebody is paying them already.
ii) nobody is questionning this (to the extent should be questioned), especially insurance companies don’t want this to go down. Because-
“More price/premium === more profit” for them.
iii) you and I don’t question this enough, as in immediate sight– we think we are not paying for that—its insurance company’s problem —
–so our attitude, “I don’t care”. I pay premium and thats it.
iv) by making the field enough complex that only few can understand and obviously to cover cost associated with expensive medical instrument (BTW, I don’t blame doctor’s for that).
Its a governments’ responsibility to make sure that the cost associated with manufacturing of medical instruments or drugs goes significantly down. How to achieve that (without compromising R&D developments). Well, thats a good question.
But I don’t think you should make choices based merely on short term goals, emotions, passion (temporary). As long as we remain honest, maintain our integrity and preserve our values and solace in our profession, we don’t need to limit our horizon (i.e., limiting our knowledge credentials).
Wow, so many heated comments but also some really wonderful ones too. I think we are all trying to sort out how to make medical practice work, regardless of specialty. The wife of medical student, I think, needs a little more life experience and humility, clearly concerned about the playing field evening in years to come. No one wants to make less money. She doesn’t realize just how transparent her comments are. Other comments here though I think have been thoughtful and reflect time and experience in healthcare. It is very tempting to cut out the middle man insurance carrier as I have considered for some time now as well; patients are even beginning to request something along those lines. They are fed up too. The healthcare reform proposals now coming down the pike may push more of our hands to do so. Change always seems to be good, even if the process is painful.
To the above wife of med student:
Just to let you know there are people who want to go into family medicine because they like the specialty, not because we are the lowest scorers on the boards. I am going into family practice and have a 95 and 99 on my Step 1 and 2 exams. Scores where I could compete for radiology or dermatology, but I am CHOOSING Family Practice because that is what I enjoy. I don’t have to make a million dollars, as long as my family is comfortable and my debts are paid. Its as simple as that.
Several corrections/clarifications are in order so that lay people are not going around misinformed –
1) docs salaries – while most specialties in between neurosurgery and primary may gross around 400k, the take home is much less, perhaps 50% less (office staff expenses, med mal premiums, etc) and this does not even take into account the typical $150,000 educational debt the average md is graduating med school with these days..
2) alternative careers for med students-medical school IS by far and away most competitive graduate program to enter/graduate from – none are even close – as for selectivity, I can’t think of any student who got into med school in my senior year (~200) whose grades would not have gotten them into the most selective B schools (Harvard and Wharton for example), and other than the very top law schools (say 10 at most, but probably more like 5) the kids matriculating at least 50 med schools would gain admission if they went into law. Another pertinent comparison- the profile of students who attend he MOST selective vet schools (Cornell and Penn e.g.) matches that of those admitted to the LEAST selective med schools
Harvard B and law schools, at its worst, still allow students to sleep each night, summer vacations (with well paid internships) don’t have weekend classes/commitments, and don’t have the very high stakes MSLE national boards to take at end of second year, which is a cumulative exam that requires med students to review 1st year material even as they are required to study 60 hours a week to master the copious amount of information thrust on them year 2….and don’t even start about the rigors of years 3 and 4, let alone residency compared to the typical “waltz in the park” that year 3 in law schools are
On the other hand
while I concur most docs couldn’t be masters of the universe on wall street or law firm (this seems obvious, as the pay and lifestyle disparities have become so great no one confident they could succeed in law or business these days would think about going o med school -NB I have an MD, JD, and MBA)
4) The real issue is not what alternatives exist for med students, or even if they are as bright and industrious as they claim – they are – the problem we have is are we recruiting the best PEOPLE to be doctors? Who in their right mind would want their docs to have the priorities, lack moral of sensibility or compassion, that typical CEO or K street lawyer has? so whether med students are the brightest is not entirely germane- if we continue to erode the attractiveness of practicing medicine (and this includes all aspects-respect, reimbursement, autonomy, litigation risk, sleep deprivation) we need entirely new model that transforms medicine from being a small business into a well respected public service that attracts the best people in our society.
Thirty years ago, my father (family practice MD) said HMOs, the middlemen of insurance, would kill the “good practice” of medicine. He was right. Two years ago, I sold my practice because of reimbursemnet challenges. I will probably return to treating patients later in life, as I love being a doctor, but when I do, I will not take insurance. You can argue semantics till the cows come home, but it not worth the hassle to fight the insurance company to pay you for what they AGREED to pay you in the first place. We’re tired of the nonsense. No more.
To be more complete with my posting:
The wife of the med student above also makes it seems that primary care doctors are all in it because they had no better choice. That is true to some but not all. About half of Harvard medical students, for example, enter into primary care. This is true for many top US medical schools.
On the other hand, there are those that want to do primary care but cannot because of their large debts and family life.
I think, your surgery resident husband has given you the picture of himself rather than the true reality. He wants to picture himself as the chosen few that are doing surgery which means he is ought to be above all others including all primary care physicians. It is precisely due to such personalities in surgery department in particular that surgery is hated and avoided by many sane and humane medical graduates.
Also to add, Neurology is not popular because the pay is low while the knowledge that one must master is very complex and ambiguous. It also requires working long with chronic patients with little hope of cure.
Finally, medical students are not the most intelligent people in our society. Concept wise, physicists and engineers are far more intelligent, far more. Anybody with brute memory and endurance can go through medical training. Small wonder why we don’t have real cures for most real diseases. But that’s also because of profit driven market scheme in medicine that deals with human life. If people start getting cured, there would be no long term dependence on those harmful drugs, which would dry up the profit. “Don’t cure or kill. Let them prolong the disease and die slowly.”
To the above wife of a med student,
You seem to know how the process of specializing work in medicine. Unfortunately you do not know completely. And that incomplete information can create dangerously false picture of reality. Let me add few things to your understanding of how it really works.
First of all, you are INCORRECT in that income ratio of each specialty is based on its difficulty level. Here is why you have that false notion. Many so called “lifestyle” specialties – dermatology, radiology, Anesthesiology, etc.- are difficult to get in NOT because they require the most difficult knowledge and skills but simply because they provide the most attractive “lifestyle” to overworked, overburdened medical graduate: less work, more money. This is why many of these specialties were not difficult to get in in the past when they were not making so much money. Believe me, once these fields stop making so much money, they will return to being mediocre specialties that many who apply can get in.
A case in point. Neurology is by far one of the hardest knowledge to master. Yet it is very easy to get in. Do you know why? Because they do not make that much money right now.
Another point. You make your husband and other surgeons look like some kind of heroes. Here is the reality. Many of them won’t be in it if the money was not there. And your motive to defend them is in question, since you, too, want your husband to be generating good income.
Lastly, the act of surgery itself is not about intelligence but more about hand coordination skill. Anybody with steady hand after enough training can cut and seal. It is a matter of experience of doing, not of intellect. This is why surgery residencies are long in training (to do enough cutting and sealing without cutting any wrong part), not because the actual surgery is immensely complex in concept. Yet, some urgeries are in fact unnecessary and don’t do much good and are rather damaging.
My point is this: a specialty is difficult to get in due to life and money. This is why DERMATOLOGY is the #1 MOST difficult specialty to get in today; yes much more than any surgery specialties. Now don’t tell me, study of skin is so much more difficult than the study of the brain. Yet Neurology is one of the easiest to get in. Ask your resident husband why? Let’s see if he will be totally honest with you.
First of all, why is it that people, in general, are willing to pay $175 for designer jeans but not for a physical exam? I have been really ill for an extended period of time before and believe me, it was proof positive that the phrase, “you have your health” carries a lot more weight than society cares to acknowledge. Just try and imagine being in constant pain. You can not enjoy anything- time with your family, your job, vacation- and you especially won’t enjoy those stupid jeans. Overall health and well-being is the foundation on which being a happy, productive citizen solely depends on.
The problem is that society never stops to consider- or maybe does not even understand- a few basic points, which I will expand upon below.
1. WE LIVE IN A CAPITALIST SYSTEM. Another day, another dollar. Everyone marks up prices to make profit, even the grocery store (and if health is a human “right” then food DEFINITELY is). Basic survival depends on profit. Without it, we can not afford a home, car or clothing. We simply can not work for free. As Tolstoy stated, “TINSTAAFL or There Is No Such Thing As A Free Lunch”. Profit is essential and inherent to the capitalist process. Example: I know someone who owns a furniture store. A typical mid to high end sofa costs, wholesale, around $500. The sticker price for the consumer? $1200. Why? Because without profit, my friend can not stay in business. The same is true for clothing, cars and even food. Some might argue that capitalism is not the way to go since this is the case, but it is BECAUSE this is the case that we enjoy a lot more choices. Without the promise of profit and the chance to continually do better, there is no incentive to work hard to provide better quality service and products. This ties in to my next point, which is…
2. MOST DOCTORS DO NOT WORK DIRECTLY FOR A HOSPTIAL Rather, 5 or 6 docs in the same specialty get together and form a clinic. Specialists like surgeons get contracts with local hospitals, who pay them per procedure. In order to justify the physicians’ use of the operationg rooms and equipment,the hospital deducts a portion of each procedure to go toward hospital overhead. Meanwhile, the physicians must take part of their earnings and put them toward the clinic staff (nurses and the receptionist who schedules your appointment)and the cost of renting the space for their clinic. Add all of that to at least 100K toward malpractice insurance and there isn’t a whole lot left. Without the all-important profit discussed in point 1, many doctors would be out of business, and many are already forced to cut back. For instance, don’t be surprised to discover that the receptionist is actually the wife of one of the physicians, who may be working for free in order to help out with expense.
3. THE SYSTEM IS SET TO A SCALE BASED ON THE ACADEMIC PERFORMANCE OF MEDICAL STUDENTS Many people mistakenly believe that any medical student may enter any field he chooses. This is not true. I repeat, this is not true. Rather, medical specialties work on a somewhat complex scale relative to academic performance with neurosurgery at the top and family practice at the bottom. Before graduating medical school, a student must be accepted into a residency program where he will be paid a modest salary (typically a little more than your average high school teacher) and will be trained to enter his field. Every field has a residency program, even family practice. Most residency programs average about 4 years with an additional 1-2 years of fellowship, although orthopedics and neurosurgery run roughly 6-7 years with 2-3 years of fellowship. These programs (there are, on average, about 2-3 programs available per state) accept a finite number of students each year through a complicated “match” program. I simply do not have the time or space to explain residency match, so I will just tell you that most students do not get the match of their choice and often must move to a city they know nothing about (and no, the residency program will not cover your relocation expenses). Neurosurgery is at the top of the scale. The program generally allows 2 residents per year, both 4.0 students at the very top of their respective classes with excellent standardized test scores. From there, everything goes in decending order, with most of the “ologies” (e.g. radiology, dermotology, pathology) falling in the middle with 5-10 residents in a 5 year program and ending with pediatrics and family practice which pretty much allow anyone who is interested. Physician pay (per procedure, as I explained before) is based on this pecking order of specialties. A typical neurosurgeon makes anywhere from 600K to 1M in a year’s time. A typical family doctor makes around 150 to 200K. All of your other specialties fall somewhere in between at 400-500K. The reasons behind this are simple: first,it takes a lot of money to buy the equipment used to perform the complex surgery that removes a cancerous brain tumor. It does not take a lot of money to buy the stethocope used to determine that you have a little congestion and need to fill a prescription for cough syrup at the pharmacy down the street. Second, the money is partly an incentive for students to become neurosurgeons, a process which requires them to study your brains out and work 24 hour periods with no sleep and few bathroom or food breaks (my husband has had to “hold it” for hours at a time, while subsisting on one yogurt cup in a 12 hour period). Plus, a surgeon’s malpractice insurance is essential and expensive, meaning that it takes more money to insure that the doctor will actually have ANY take-home pay after covering expenses. The idea behind the whole system comes down to one objective: only the best and brightest are allowed to perform procedures in life or death situations and trust me, you don’t want it any other way. A C- student simply can not be allowed to practice that type of medicine because he does not posses the skills required to yield a successful outcome. And the fact is, one tiny error could be disastrous.
So, there you have it. The AMA is not conspiring to undermine the system, but has actually set up a system which benefits all and insures that ONLY SOMEONE WHO REALLY KNOWS WHAT HE IS DOING WILL OPERATE ON YOUR BRAIN OR HEART. The primary care doctors DO understand this, but take advantage of the fact that the general public does not. As cold and elitist as it may seem, most primary care doctors are jeolous of their more intelligent peers who were actually allowed (yes, I used the word ALLOWED because really, that is what it comes down to) the opportunity to make it in one of the more difficult fields. The primary care doctor was NOT allowed to persue a more lucrative career because they simply did not have the grades or nationally standardized test scores (STEP 1 and STEP 2) to be accepted into the residency program. Many students choose family medicine as a “back up” if the other doesn’t work out. Primary care doctors would love to see a socialized system, for no other reason than it would force the wealthy specialists out of their lifestyles, thus freeing the family doc from the debt that he has accrued from trying to live up to the “physician image.” The truth is, that guy really can’t afford the BMW or country club membership, but he can’t stand passing up the opportunity to enjoy the status afforded him by the oblivious general public. I know this is true because I have had more than one family doctor (as well as an ob-gyn and even a dentist) tell me that my husband needs to work toward, “whatever makes the most money”. Trust me, if given the chance, these guys would LEAP at a job in surgery. Surgeons are not only esteemed members of the community, but are elite even in the physician circle, as well they should be, since it takes UNBELIEVABLE intellgence, commitment and focus (not to mention little to no social life) to become a surgeon. If the pay were suddenly something less, most students would not put themselves through that kind of brutality. It is easy for an outsider to scorn that last sentence, but let’s consider the fact that the American mantra these days seems to be, “make the most money doing as little as possible.” And when you consider the type work that surgeons do as compared to the millions paid to people doing non-essential things like entertaining the masses in movies or at ballgames, I think it all evens out. And I think that most would agree.
First of all, why is it that people, in general, are willing to pay $175 for designer jeans but not for a physical exam? I have been really ill for an extended period of time before and believe me, it was proof positive that the phrase, “you have your health” carries a lot more weight than society cares to acknowledge. Just try and imagine being in constant pain. You can not enjoy anything- time with your family, your job, vacation- and you especially won’t enjoy those stupid jeans. Overall health and well-being is the foundation on which being a happy, productive citizen solely depends on.
The problem is that society never stops to consider- or maybe does not even understand- a few basic points, which I will expand upon below.
1. WE LIVE IN A CAPITALIST SYSTEM. Another day, another dollar. Everyone marks up prices to make profit, even the grocery store (and if health is a human “right” then food DEFINITELY is). Basic survival depends on profit. Without it, we can not afford a home, car or clothing. We simply can not work for free. As Tolstoy stated, “TINSTAAFL or There Is No Such Thing As A Free Lunch”. Profit is essential and inherent to the capitalist process. Example: I know someone who owns a furniture store. A typical mid to high end sofa costs, wholesale, around $500. The sticker price for the consumer? $1200. Why? Because without profit, my friend can not stay in business. The same is true for clothing, cars and even food. Some might argue that capitalism is not the way to go since this is the case, but it is BECAUSE this is the case that we enjoy a lot more choices. Without the promise of profit and the chance to continually do better, there is no incentive to work hard to provide better quality service and products. This ties in to my next point, which is…
2. MOST DOCTORS DO NOT WORK DIRECTLY FOR A HOSPTIAL Rather, 5 or 6 docs in the same specialty get together and form a clinic. Specialists like surgeons get contracts with local hospitals, who pay them per procedure. In order to justify the physicians’ use of the operationg rooms and equipment,the hospital deducts a portion of each procedure to go toward hospital overhead. Meanwhile, the physicians must take part of their earnings and put them toward the clinic staff (nurses and the receptionist who schedules your appointment)and the cost of renting the space for their clinic. Add all of that to at least 100K toward malpractice insurance and there isn’t a whole lot left. Without the all-important profit discussed in point 1, many doctors would be out of business, and many are already forced to cut back. For instance, don’t be surprised to discover that the receptionist is actually the wife of one of the physicians, who may be working for free in order to help out with expense.
3. THE SYSTEM IS SET TO A SCALE BASED ON THE ACADEMIC PERFORMANCE OF MEDICAL STUDENTS Many people mistakenly believe that any medical student may enter any field he chooses. This is not true. I repeat, this is not true. Rather, medical specialties work on a somewhat complex scale relative to academic performance with neurosurgery at the top and family practice at the bottom. Before graduating medical school, a student must be accepted into a residency program where he will be paid a modest salary (typically a little more than your average high school teacher) and will be trained to enter his field. Every field has a residency program, even family practice. Most residency programs average about 4 years with an additional 1-2 years of fellowship, although orthopedics and neurosurgery run roughly 6-7 years with 2-3 years of fellowship. These programs (there are, on average, about 2-3 programs available per state) accept a finite number of students each year through a complicated “match” program. I simply do not have the time or space to explain residency match, so I will just tell you that most students do not get the match of their choice and often must move to a city they know nothing about (and no, the residency program will not cover your relocation expenses). Neurosurgery is at the top of the scale. The program generally allows 2 residents per year, both 4.0 students at the very top of their respective classes with excellent standardized test scores. From there, everything goes in decending order, with most of the “ologies” (e.g. radiology, dermotology, pathology) falling in the middle with 5-10 residents in a 5 year program and ending with pediatrics and family practice which pretty much allow anyone who is interested. Physician pay (per procedure, as I explained before) is based on this pecking order of specialties. A typical neurosurgeon makes anywhere from 600K to 1M in a year’s time. A typical family doctor makes around 150 to 200K. All of your other specialties fall somewhere in between at 400-500K. The reasons behind this are simple: first,it takes a lot of money to buy the equipment used to perform the complex surgery that removes a cancerous brain tumor. It does not take a lot of money to buy the stethocope used to determine that you have a little congestion and need to fill a prescription for cough syrup at the pharmacy down the street. Second, the money is partly an incentive for students to become neurosurgeons, a process which requires them to study your brains out and work 24 hour periods with no sleep and few bathroom or food breaks (my husband has had to “hold it” for hours at a time, while subsisting on one yogurt cup in a 12 hour period). Plus, a surgeon’s malpractice insurance is essential and expensive, meaning that it takes more money to insure that the doctor will actually have ANY take-home pay after covering expenses. The idea behind the whole system comes down to one objective: only the best and brightest are allowed to perform procedures in life or death situations and trust me, you don’t want it any other way. A C- student simply can not be allowed to practice that type of medicine because he does not posses the skills required to yield a successful outcome. And the fact is, one tiny error could be disastrous.
So, there you have it. The AMA is not conspiring to undermine the system, but has actually set up a system which benefits all and insures that ONLY SOMEONE WHO REALLY KNOWS WHAT HE IS DOING WILL OPERATE ON YOUR BRAIN OR HEART. The primary care doctors DO understand this, but take advantage of the fact that the general public does not. As cold and elitist as it may seem, most primary care doctors are jeolous of their more intelligent peers who were actually allowed (yes, I used the word ALLOWED because really, that is what it comes down to) the opportunity to make it in one of the more difficult fields. The primary care doctor was NOT allowed to persue a more lucrative career because they simply did not have the grades or nationally standardized test scores (STEP 1 and STEP 2) to be accepted into the residency program. Many students choose family medicine as a “back up” if the other doesn’t work out. Primary care doctors would love to see a socialized system, for no other reason than it would force the wealthy specialists out of their lifestyles, thus freeing the family doc from the debt that he has accrued from trying to live up to the “physician image.” The truth is, that guy really can’t afford the BMW or country club membership, but he can’t stand passing up the opportunity to enjoy the status afforded him by the oblivious general public. I know this is true because I have had more than one family doctor (as well as an ob-gyn and even a dentist) tell me that my husband needs to work toward, “whatever makes the most money”. Trust me, if given the chance, these guys would LEAP at a job in surgery. Surgeons are not only esteemed members of the community, but are elite even in the physician circle, as well they should be, since it takes UNBELIEVABLE intellgence, commitment and focus (not to mention little to no social life) to become a surgeon. If the pay were suddenly something less, most students would not put themselves through that kind of brutality. It is easy for an outsider to scorn that last sentence, but let’s consider the fact that the American mantra these days seems to be, “make the most money doing as little as possible.” And when you consider the type work that surgeons do as compared to the millions paid to people doing non-essential things like entertaining the masses in movies or at ballgames, I think it all evens out. And I think that most would agree.
First of all, why is it that people, in general, are willing to pay $175 for designer jeans but not for a physical exam? I have been really ill for an extended period of time before and believe me, it was proof positive that the phrase, “you have your health” carries a lot more weight than society cares to acknowledge. Just try and imagine being in constant pain. You can not enjoy anything- time with your family, your job, vacation- and you especially won’t enjoy those stupid jeans. Overall health and well-being is the foundation on which being a happy, productive citizen solely depends on.
The problem is that society never stops to consider- or maybe does not even understand- a few basic points, which I will expand upon below.
1. WE LIVE IN A CAPITALIST SYSTEM. Another day, another dollar. Everyone marks up prices to make profit, even the grocery store (and if health is a human “right” then food DEFINITELY is). Basic survival depends on profit. Without it, we can not afford a home, car or clothing. We simply can not work for free. As Tolstoy stated, “TINSTAAFL or There Is No Such Thing As A Free Lunch”. Profit is essential and inherent to the capitalist process. Example: I know someone who owns a furniture store. A typical mid to high end sofa costs, wholesale, around $500. The sticker price for the consumer? $1200. Why? Because without profit, my friend can not stay in business. The same is true for clothing, cars and even food. Some might argue that capitalism is not the way to go since this is the case, but it is BECAUSE this is the case that we enjoy a lot more choices. Without the promise of profit and the chance to continually do better, there is no incentive to work hard to provide better quality service and products. This ties in to my next point, which is…
2. MOST DOCTORS DO NOT WORK DIRECTLY FOR A HOSPTIAL Rather, 5 or 6 docs in the same specialty get together and form a clinic. Specialists like surgeons get contracts with local hospitals, who pay them per procedure. In order to justify the physicians’ use of the operationg rooms and equipment,the hospital deducts a portion of each procedure to go toward hospital overhead. Meanwhile, the physicians must take part of their earnings and put them toward the clinic staff (nurses and the receptionist who schedules your appointment)and the cost of renting the space for their clinic. Add all of that to at least 100K toward malpractice insurance and there isn’t a whole lot left. Without the all-important profit discussed in point 1, many doctors would be out of business, and many are already forced to cut back. For instance, don’t be surprised to discover that the receptionist is actually the wife of one of the physicians, who may be working for free in order to help out with expense.
3. THE SYSTEM IS SET TO A SCALE BASED ON THE ACADEMIC PERFORMANCE OF MEDICAL STUDENTS Many people mistakenly believe that any medical student may enter any field he chooses. This is not true. I repeat, this is not true. Rather, medical specialties work on a somewhat complex scale relative to academic performance with neurosurgery at the top and family practice at the bottom. Before graduating medical school, a student must be accepted into a residency program where he will be paid a modest salary (typically a little more than your average high school teacher) and will be trained to enter his field. Every field has a residency program, even family practice. Most residency programs average about 4 years with an additional 1-2 years of fellowship, although orthopedics and neurosurgery run roughly 6-7 years with 2-3 years of fellowship. These programs (there are, on average, about 2-3 programs available per state) accept a finite number of students each year through a complicated “match” program. I simply do not have the time or space to explain residency match, so I will just tell you that most students do not get the match of their choice and often must move to a city they know nothing about (and no, the residency program will not cover your relocation expenses). Neurosurgery is at the top of the scale. The program generally allows 2 residents per year, both 4.0 students at the very top of their respective classes with excellent standardized test scores. From there, everything goes in decending order, with most of the “ologies” (e.g. radiology, dermotology, pathology) falling in the middle with 5-10 residents in a 5 year program and ending with pediatrics and family practice which pretty much allow anyone who is interested. Physician pay (per procedure, as I explained before) is based on this pecking order of specialties. A typical neurosurgeon makes anywhere from 600K to 1M in a year’s time. A typical family doctor makes around 150 to 200K. All of your other specialties fall somewhere in between at 400-500K. The reasons behind this are simple: first,it takes a lot of money to buy the equipment used to perform the complex surgery that removes a cancerous brain tumor. It does not take a lot of money to buy the stethocope used to determine that you have a little congestion and need to fill a prescription for cough syrup at the pharmacy down the street. Second, the money is partly an incentive for students to become neurosurgeons, a process which requires them to study your brains out and work 24 hour periods with no sleep and few bathroom or food breaks (my husband has had to “hold it” for hours at a time, while subsisting on one yogurt cup in a 12 hour period). Plus, a surgeon’s malpractice insurance is essential and expensive, meaning that it takes more money to insure that the doctor will actually have ANY take-home pay after covering expenses. The idea behind the whole system comes down to one objective: only the best and brightest are allowed to perform procedures in life or death situations and trust me, you don’t want it any other way. A C- student simply can not be allowed to practice that type of medicine because he does not posses the skills required to yield a successful outcome. And the fact is, one tiny error could be disastrous.
So, there you have it. The AMA is not conspiring to undermine the system, but has actually set up a system which benefits all and insures that ONLY SOMEONE WHO REALLY KNOWS WHAT HE IS DOING WILL OPERATE ON YOUR BRAIN OR HEART. The primary care doctors DO understand this, but take advantage of the fact that the general public does not. As cold and elitist as it may seem, most primary care doctors are jeolous of their more intelligent peers who were actually allowed (yes, I used the word ALLOWED because really, that is what it comes down to) the opportunity to make it in one of the more difficult fields. The primary care doctor was NOT allowed to persue a more lucrative career because they simply did not have the grades or nationally standardized test scores (STEP 1 and STEP 2) to be accepted into the residency program. Many students choose family medicine as a “back up” if the other doesn’t work out. Primary care doctors would love to see a socialized system, for no other reason than it would force the wealthy specialists out of their lifestyles, thus freeing the family doc from the debt that he has accrued from trying to live up to the “physician image.” The truth is, that guy really can’t afford the BMW or country club membership, but he can’t stand passing up the opportunity to enjoy the status afforded him by the oblivious general public. I know this is true because I have had more than one family doctor (as well as an ob-gyn and even a dentist) tell me that my husband needs to work toward, “whatever makes the most money”. Trust me, if given the chance, these guys would LEAP at a job in surgery. Surgeons are not only esteemed members of the community, but are elite even in the physician circle, as well they should be, since it takes UNBELIEVABLE intellgence, commitment and focus (not to mention little to no social life) to become a surgeon. If the pay were suddenly something less, most students would not put themselves through that kind of brutality. It is easy for an outsider to scorn that last sentence, but let’s consider the fact that the American mantra these days seems to be, “make the most money doing as little as possible.” And when you consider the type work that surgeons do as compared to the millions paid to people doing non-essential things like entertaining the masses in movies or at ballgames, I think it all evens out. And I think that most would agree.
First of all, why is it that people, in general, are willing to pay $175 for designer jeans but not for a physical exam? I have been really ill for an extended period of time before and believe me, it was proof positive that the phrase, “you have your health” carries a lot more weight than society cares to acknowledge. Just try and imagine being in constant pain. You can not enjoy anything- time with your family, your job, vacation- and you especially won’t enjoy those stupid jeans. Overall health and well-being is the foundation on which being a happy, productive citizen solely depends on.
The problem is that society never stops to consider- or maybe does not even understand- a few basic points, which I will expand upon below.
1. WE LIVE IN A CAPITALIST SYSTEM. Another day, another dollar. Everyone marks up prices to make profit, even the grocery store (and if health is a human “right” then food DEFINITELY is). Basic survival depends on profit. Without it, we can not afford a home, car or clothing. We simply can not work for free. As Tolstoy stated, “TINSTAAFL or There Is No Such Thing As A Free Lunch”. Profit is essential and inherent to the capitalist process. Example: I know someone who owns a furniture store. A typical mid to high end sofa costs, wholesale, around $500. The sticker price for the consumer? $1200. Why? Because without profit, my friend can not stay in business. The same is true for clothing, cars and even food. Some might argue that capitalism is not the way to go since this is the case, but it is BECAUSE this is the case that we enjoy a lot more choices. Without the promise of profit and the chance to continually do better, there is no incentive to work hard to provide better quality service and products. This ties in to my next point, which is…
2. MOST DOCTORS DO NOT WORK DIRECTLY FOR A HOSPTIAL Rather, 5 or 6 docs in the same specialty get together and form a clinic. Specialists like surgeons get contracts with local hospitals, who pay them per procedure. In order to justify the physicians’ use of the operationg rooms and equipment,the hospital deducts a portion of each procedure to go toward hospital overhead. Meanwhile, the physicians must take part of their earnings and put them toward the clinic staff (nurses and the receptionist who schedules your appointment)and the cost of renting the space for their clinic. Add all of that to at least 100K toward malpractice insurance and there isn’t a whole lot left. Without the all-important profit discussed in point 1, many doctors would be out of business, and many are already forced to cut back. For instance, don’t be surprised to discover that the receptionist is actually the wife of one of the physicians, who may be working for free in order to help out with expense.
3. THE SYSTEM IS SET TO A SCALE BASED ON THE ACADEMIC PERFORMANCE OF MEDICAL STUDENTS Many people mistakenly believe that any medical student may enter any field he chooses. This is not true. I repeat, this is not true. Rather, medical specialties work on a somewhat complex scale relative to academic performance with neurosurgery at the top and family practice at the bottom. Before graduating medical school, a student must be accepted into a residency program where he will be paid a modest salary (typically a little more than your average high school teacher) and will be trained to enter his field. Every field has a residency program, even family practice. Most residency programs average about 4 years with an additional 1-2 years of fellowship, although orthopedics and neurosurgery run roughly 6-7 years with 2-3 years of fellowship. These programs (there are, on average, about 2-3 programs available per state) accept a finite number of students each year through a complicated “match” program. I simply do not have the time or space to explain residency match, so I will just tell you that most students do not get the match of their choice and often must move to a city they know nothing about (and no, the residency program will not cover your relocation expenses). Neurosurgery is at the top of the scale. The program generally allows 2 residents per year, both 4.0 students at the very top of their respective classes with excellent standardized test scores. From there, everything goes in decending order, with most of the “ologies” (e.g. radiology, dermotology, pathology) falling in the middle with 5-10 residents in a 5 year program and ending with pediatrics and family practice which pretty much allow anyone who is interested. Physician pay (per procedure, as I explained before) is based on this pecking order of specialties. A typical neurosurgeon makes anywhere from 600K to 1M in a year’s time. A typical family doctor makes around 150 to 200K. All of your other specialties fall somewhere in between at 400-500K. The reasons behind this are simple: first,it takes a lot of money to buy the equipment used to perform the complex surgery that removes a cancerous brain tumor. It does not take a lot of money to buy the stethocope used to determine that you have a little congestion and need to fill a prescription for cough syrup at the pharmacy down the street. Second, the money is partly an incentive for students to become neurosurgeons, a process which requires them to study your brains out and work 24 hour periods with no sleep and few bathroom or food breaks (my husband has had to “hold it” for hours at a time, while subsisting on one yogurt cup in a 12 hour period). Plus, a surgeon’s malpractice insurance is essential and expensive, meaning that it takes more money to insure that the doctor will actually have ANY take-home pay after covering expenses. The idea behind the whole system comes down to one objective: only the best and brightest are allowed to perform procedures in life or death situations and trust me, you don’t want it any other way. A C- student simply can not be allowed to practice that type of medicine because he does not posses the skills required to yield a successful outcome. And the fact is, one tiny error could be disastrous.
So, there you have it. The AMA is not conspiring to undermine the system, but has actually set up a system which benefits all and insures that ONLY SOMEONE WHO REALLY KNOWS WHAT HE IS DOING WILL OPERATE ON YOUR BRAIN OR HEART. The primary care doctors DO understand this, but take advantage of the fact that the general public does not. As cold and elitist as it may seem, most primary care doctors are jeolous of their more intelligent peers who were actually allowed (yes, I used the word ALLOWED because really, that is what it comes down to) the opportunity to make it in one of the more difficult fields. The primary care doctor was NOT allowed to persue a more lucrative career because they simply did not have the grades or nationally standardized test scores (STEP 1 and STEP 2) to be accepted into the residency program. Many students choose family medicine as a “back up” if the other doesn’t work out. Primary care doctors would love to see a socialized system, for no other reason than it would force the wealthy specialists out of their lifestyles, thus freeing the family doc from the debt that he has accrued from trying to live up to the “physician image.” The truth is, that guy really can’t afford the BMW or country club membership, but he can’t stand passing up the opportunity to enjoy the status afforded him by the oblivious general public. I know this is true because I have had more than one family doctor (as well as an ob-gyn and even a dentist) tell me that my husband needs to work toward, “whatever makes the most money”. Trust me, if given the chance, these guys would LEAP at a job in surgery. Surgeons are not only esteemed members of the community, but are elite even in the physician circle, as well they should be, since it takes UNBELIEVABLE intellgence, commitment and focus (not to mention little to no social life) to become a surgeon. If the pay were suddenly something less, most students would not put themselves through that kind of brutality. It is easy for an outsider to scorn that last sentence, but let’s consider the fact that the American mantra these days seems to b