Making A List and Checking It Twice

Goozner Allow me to call readers attention to an article in the latest issue of the New England Journal of Medicine that calls on medical specialty societies to make lists of the five most wasteful practices in their sub-specialties and develop programs to educate their colleagues about how to cut back on these wasteful practices.

Howard Brody, who heads the Institute for Medical Humanities at the University of Texas Galveston Branch Medical School, points out that most stakeholders in health care reform — the drug companies, the insurance companies, the medical device companies, taxpayers, Medicare beneficiaries — have been asked to give up something to insure the uninsured. But physicians?

Although major professional organizations have endorsed various reform measures, no promises have been made in terms of cutting any future medical costs. Indeed, in some cases, physician support has been made contingent on promises that physicians’ income would not be negatively affected by reform.

It’s appropriate to question the ethics of this stance, he writes.

To honor Dr. Brody’s excellent suggestion, allow me to throw the following information into the mix, courtesy of the annual American Medical Group Association physician salary survey. What follows are the median (50 percent earn more, 50 percent earn less) salaries for the six highest-paying and six lowest-paying medical specialties in 2009:

Five Highest

Orthopedic surgeons —                         $580,711 to $641,728

Cardiac and thoracic surgeons —           $507,143

Radiologists —                                     $438,115 to $478,000

Radiation therapy —                             $413,518

Gynecological oncology —                    $406,000

Cardiology —                                       $398,034

Five Lowest

Family Medicine —                               $197,655

Pediatrics —                                        $202,832

Internal Medicine —                              $205,441

Psychiatry —                                       $208,462

Geriatrics —                                         $211,425

Hospitalists —                                      $211,835

(For the full list, click here.)

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  1. Re Sick of the whining’s comment above:
    You missed the point of my comment per your reply. Maybe a good portion of what causes people to live or die are the choices they make that then brings them into the office, expecting us to save their lives after they have compromised it beyond repair. And, guess what, Sotw, a sizeable amount of patients do think we can overcome the odds and restore their health as only a God could do, and then sue us when we aren’t able to succeed. So, my point to my comment is I am only an MD, not a GOD. Yes, some doctors act like they are GODs, and that gets them into trouble.
    It would be fascinating to see how quickly the country would get pissed off if doctors went on strike to refute this pending madness by politicians. What is the adage again, “absence makes the heart grow fonder”?
    Sick of the whining? Me, sick of dismissing legitimate feelings of concerned and committed doctors who are taken for granted. Again, walk in our shoes for a while. Don’t think you’ll get far!

  2. ExhaustedMD –
    “Higher standard of accountability because of what the MD degree creates”
    You and your colleagues are held to higher standards of accountability because what you do causes people to live or die, not because of the letters after your name. Kind of missing the forest for the trees, aren’t you?

  3. As a consumer whose healthcare insurance is going up again and someone who can’t afford the deductible right now to repair a botched foot surgery, I’m glad this issue of physician accountability is being addressed in a public forum.
    This isn’t sour grapes, as I’m very grateful for the excellent care I received with a previous cancer diagnosis (clean bill of health now, TG) but I just finished reading a new book, Bend the Health Care Trend, that opened my eyes to the value of a consumer driven healthcare plan (CDRP). A CDRP would increase physician transparency and accountability. This book should be required reading for all physicians and hospital boards. @Dr. Lippin, your questions are a great start to creating patient engagement.

  4. I am going to do some triagulation here and give primary care a way to save money.
    It has been known (but denied) for decades that up to 80% of visits to primary care docs are stress related.
    So for many years I have been unsuccessfully petitioning JCAHO to add the following to their standards.
    Here are two simple mandatory questions that need to be asked by your primary doctor during every patient visit. If your doctor does NOT ask these – find another doctor.These questions will change US medical practice and save a lot of money.
    Proposed by Dr. Rick Lippin, June, 2002
    Propose that all health care providers (especially primary care providers) ask adult * patients two simple questions when taking the medical history during every patient visit. Using the JCAHO model for pain (JCAHO’s so called 5th vital sign) patents would report levels from 1 to 10. The questions are simply:
    “ How are things at work?”*
    “ How are things at home?”
    1= “couldn’t be better”
    10= “couldn’t be worse” (in crisis stage)
    The answers to these questions could then lead to referrals and standardized tests for further diagnostic workup for stress and depression and they would not “burden” the primary care providers with a requirement to do a full exploration of the problems very likely to be elicited
    * for students substitute word “school” for “work”
    But alas the consensual denial between patients and their doctors continues. And the unnecessary tests are ordered and the unnecessary (and often unsafe) pills are pushed.
    Dr. Rick Lippin

  5. There are also those exhausted women in Bangladesh etc who travel for miles to cut wood, care for house, do odd jobs to earn livelihood and pamper drunk husbands. They don’t make that kind of money for being on hook 24X7.
    No link is being made doctor salary and cost cutting, though it is inevitable there will be some impact.
    May I ask this question- since doctors are so overworked would they welcome import of foreign doctors to relieve this burden on their shoulders?

  6. First of all, in response to jd after my last posting above, I don’t understand your reply to my income, based on how many years I have practiced. I read of employment postings for the past 5 years that quote incomes of 200K or more at the start of the job in my field, and it doesn’t note limitations to the number of years in practice to apply for the job, so the number of years one is practicing does not greatly diminish income opportunity, at least of late. Also, I disagree with your comment that all income posted for a physician is related to health care. If in fact the author of this post is basing it on W-2 statements, then there could be a skewing of the numbers if doctors are getting income from outside business ventures that may have nothing to do with health care. I know of one doctor who has real estate ventures at hand, which supplements his income so he works less as a physician. So, if he makes 200K on this alone, and pulls in 200K in his work as a doctor, his 400K total does NOT reflect his physician income alone, true?
    Again, to all these commenters who are NOT physicians, let me just say one thing I would hope the physician readers would at least partially agree with me: if you haven’t made the committment to medicine, which is beyond just going to medical school and residency, you really have no idea what the responsible and dedicated doctor gives up to be an MD. You don’t have the lifestyle of your contemporaries, who finish college around 22 or 23 and start making an income and working a 9 to 5 job, having weekends free, never having to carry a pager on average every 4 to 6 nights, never carrying malpractice insurance, probably not dealing with people who demand and not ask for services they may not truly need, and aren’t held to a higher standard of accountability because of what the MD degree creates. People don’t realize that when you are a doctor, and work the job as asked, you give up things that the average American takes for granted. So, I don’t feel guilt or shame having an income stream that is a bit higher than other white collar professionals, because I earn it and I sacrifice for it.
    Walk in the shoes of a doctor for a month or so, and then come back with whatever criticisms or judgments you feel you can still provide. We are taken for granted and asked to basically be like priests. Hey, no vow of poverty here! And, remember, the initials after our names are MD, not GOD!

  7. Barry – If you stood up in front of a room of physicians and made those comments (even though there is alot of underlying true to them), they would come after you with picks and torches.
    Physicians are unfairly demonized because of the salary they make and freshly graduated MDs do have some legitimate issues about their large debt burdens. Still, it is hard for me to listen to physicians (especially specialists) largely cry ‘wolf’ about their income. By any rational measure whether it is physicians in any other country or by most occupations in this country, physicians are among the best-paid professionals and have little/no chance of becoming unemployed or underemployed during their professional lives if they have a private practice.
    As for the current reform bill, the only thing physicians didn’t get was a hard cap on liability and any immediate reform. Otherwise the SGR formula is going to be modified and the cuts that keep getting kicked down the road are going to be backfilled in entirety. That is a huge cost and one of the largest costs in the bill.
    Finally, physicians have been involved at the table in terms of reform. It just varies greatly from specialty society to society. It comes back to the issue though that you have a payment system that does not encourage physicians to reduce utilization and activities associated with it. Instead, it is still “eat what you kill.”

  8. Actually there is this interesting section in the reform bill-
    I would like to know the same about my doctors. At least for my dermatologist who prescribed me $351 medicine for spots on my neck that I was able to home-cure using $3 anti-dandruff Equate shampoo from Walmart and faced no side effects of steroids that I would have encountered with prescribed medicine.
    This might make the relations with doctors a bit piquant with patients construing financial motives behind doctor’s all moves. Yet, as we know absolute power leads to absolute corruption, we will be better off having some checks in place whereby doctors know that their activities will be known to end receipients of their service.

  9. I wish these discussions would make a distinction between profit and professional compensation. They are not the same.
    “Profit” is a business term describing the bottom line of a P&L statement. It may be operational profit, pre-tax profit or net profit. And it may be payable as money, dividends, stocks or options.
    “Compensation” is a business expense. In addition to the paycheck, it includes whatever benefits may be included.
    Part of the confusion derives from physicians being better at medicine than at business, leaving business details to other professionals (like lawyers, CPA’s or tax accountants).
    It is revealing that an invitation to submit ideas of how better to reduce COSTS triggers a discussion about how much doctors get paid. Though the intent us not here, this is a very poor defense of the fee-for-service model.

  10. Margalit,
    Every time employee base shrinks while the work doesn’t that’s a sacrifice made by remaining employees. Now what insurance does with new found saving is another issue. This may just make a small dent into costs and may not be enough to reduce premiums. However no one is trying to reduce premiums. We can only slow down their growth rate to that of inflation rate. And if all stakeholders can do little bit that just might be enough.
    Hence the pertinent question to doctors in the article- what are they doing and how are they contributing?
    I fully agree that financial comfort is not conducive to activism, though doctors do have their fair share of renegades and liberals. Just that cost reduction isn’t one of their favorite areas. They just might become bit more of financial planners for their customers if they would like to, for their patients.

  11. “… but I assure you that we are not always the main producers of waste in the system.”
    Dr. Motew, I happen to agree with your statement above. However, physicians are in a position to be the main drivers of elimination of such waste and for some reason they are reluctant to take a voluntary leadership role in this effort. I believe that was the point Dr. Brody was trying to make in his article.
    I see Merrill’s listing of salaries not as an indictment, but as a possible explanation of why physicians as a group are inactive. Financial comfort is not conducive to activism.
    Vikram, I am not inclined to consider layoffs or off-shoring as a measure of sacrifice for the benefit of the uninsured. These are operational steps aimed at preserving and increasing profits, particularly in a bad economy, and interestingly enough, with all this newly found efficiencies, premiums are still going up with no end in sight.

  12. Good to see so many physicians on board and I would say thet deserve their compensation. Yet if I were to be asked what is the value of the physician, I would like a developed market to determine that.
    No physician will treat you for free apart from during the charity hours they might be contributing at certain location.
    Considering above it will be best if doctors themselves decide where they want cuts in the system and in their share of the system and how they would like to be part of marketplace that pays for performance.
    MD as Hell has his point about demanding patients, yet he needs to make sure that his experience of ERs does not color the perception of entire industry. Most patients in other situations are still very docile and uneducated. Also about your point of patients having to wait for claims payment, that can happen if doctors themselves are willing to talk price to patients, guarantee that they will perform only contract approved
    procedures, use right procedure code, do not do any balance billing and indicate to patients when they are deviating from standard practice.
    I just have a bill from hospital for my kid born 2.5 years back and a negative remark in credit history because the pediatrician’s office sent bills for two kids in one kids name and then handed case to collection agency. We kept ping ponging between them because they refuse to share details of the case owing to privacy issue. Where are the physician values in such cases?
    I think there is this underrated benefit of insurance industry of fighting out with doctor’s billing office on behalf of patients and negotiating prices in advance.
    Also to Margalit, insurance industry has done a lot of layoffs over this year and will continue doing so in 2010. Aetna and many BCBS has done that and additionally a lot of IT work will be offshored.

  13. To return the discussion away from salaries and back to the main suggestion of Dr. Brody’s article- I thought that readers might be interested to know that these “top five” lists are already being developed for primary care specialties by the National Physicians Alliance (http://npalliance.org/). This initiative is being funded through one of the ABIM Foundation’s “Putting the Charter into Practice” grants, which fund organizations to develop initiatives to advance physician professionalism, including management of finite resources. I encourage you to visit the Foundation’s website to find out more and join in our discussions of professionalism:
    Amy Cunningham, MPH
    Program Administrator/Analyst
    ABIM Foundation

  14. Barry,
    I agree, and as a physician feel that collectively we have done a poor job taking the leadership in cost-containment, efficiency and quality, hence our minimal involvement at the table for reform.
    I do not agree with the many posts here suggesting that wasteful practice is mainly motivated by doctors wanting to protect their income (though certainly that exists). Throughout the political process this past year, we have been cast in a relatively unfavorable role as ‘greedy’ and ‘inefficient’ and wasteful. This is a PR nightmare that does not do justice to the actual commitment and work that most of us bring to the table. Continually tying salary levels to our current practice is simply over-simplifying the ‘problem’, but I assure you that we are not always the main producers of waste in the system. At the heart of the matter, as I posted above, is “What is the true value of a physician?” and how do we as a society recognize this? We obviously have not been doing a great job in the eyes of the public. Perhaps we need to redefine this as it relates to ‘other’ occupations: degree of training, time spent practicing, legal exposure, stress, severity AND of course successful outcomes quality and efficiency. In this light, I am sure that docs would be valued much higher than we are now, and perhaps society would agree that we earn our income much more so than CEOs, pro-athletes and plumbers!

  15. As Paul Starr described in his Pulitzer Prize winning 1982 book, “The Social Transformation of American Medicine,” doctors have a decades long history of trying (usually successfully) to stifle and thwart competition at every turn. Anything that threatens their income or their power is anathema to them. They oppose everything from retail clinics staffed by NP’s, to allowing NP’s to more fully utilize their skills, to developing pay for performance metrics that they can live with to disclosing their insurer contract rates for the services they provide. In the current reform debate, they are clamoring for tort reform, which I support, and the elimination of Medicare’s SGR formula. They have offered no suggestions that will reduce costs because it would threaten their own income. Yet, their decisions to order tests, prescribe drugs, admit patients to the hospital, refer to specialists, consult with patients and perform procedures themselves drive virtually all healthcare spending that insurers and taxpayers pay for. Exceptions include long term custodial care in a nursing home or the patient’s home, public health initiatives and R&D. It appears to me that doctors, who are in a key position to provide leadership in ferreting out waste in the system, just want to solve the problem at someone else’s expense. I repeat my often asked question regarding healthcare and health insurance reform including bending the medical cost growth curve. What’s your contribution?

  16. “how does streamlining a process and reducing the costs to the company translate into “sacrifice”?”
    Margalit – Presumably, there will be significant investments in technology and new processes to achieve the streamlining. Insurers will have to pay for those upfront investments. Interestingly, their anti-trust exemption, other things equal, should make that effort easier for the industry to execute.
    Separately, I think we in the U.S. do utilize significantly more expensive care than patients in other countries do. I’m referring mainly to often futile end of life care including lengthy stays in an ICU at $10K per day, new, very costly, and sometimes experimental care to treat late stage cancers where a course of treatment can easily run to tens of thousands of dollars, etc. I think we do this for a combination of three reasons. First, providers (doctors and hospitals) are paid more for doing more. Second, providers fear they may be sued if they don’t “do everything” in the absence of clear instructions to the contrary. Third, many patients routinely want and expect every medical intervention that we can offer if it will prolong life even a little and they expect someone else (taxpayers and insurers) to pay for it. Many of these options would not even be offered to patients in other countries because of differences in how good, sound medical practice is defined and applied.
    I indicated in a prior post that patients in France and Japan visit the doctor more often than a typical American. Most of this is indeed for basic primary care which is not costly while each visit is considerably cheaper than in would be here to begin with.
    As an aside, primary care doctors in the UK are paid on a capitated basis. They can also earn pay for performance payments, which are quite significant, based on how well they do on dozens of separate metrics. The UK doctor featured in the section on the UK system in Reid’s book earned $296,000 per year while primary care docs in the UK actually earn more than specialists. Overall in the UK, however, they simply do less of everything because the society made a choice to spend less on healthcare than most other countries which frees up resources for other priorities. Overall taxation, including a 17.5% Value Added Tax, is very high by U.S. standards as it is throughout Western Europe and Canada.

  17. jd, how does streamlining a process and reducing the costs to the company translate into “sacrifice”?

  18. ExhaustedMD: if you’ve practiced for 10 years it shouldn’t be too surprising that you have earned less than the median amount. The average career is, what, 30-40 years? In any event, I’m sure the concept of a median is familiar to you.
    As for the remark about other sources of income, it is all coming from health care expenditures, isn’t it? A surgeon might own a share in a for-profit hospital or surgical center and get an extra $100K a year out of that. Do you think that money is any less likely to come from overutilization of services? More likely, actually.
    To those who have questioned the numbers, there are dozens of physician income surveys out there and while the surveys vary somewhat, the overall picture is consistent.
    As for connecting the dots between Goozner’s remarks, it isn’t hard. The point is that we will not control health care costs unless every part of the system takes a hit on revenue and growth trend. As this applies to physicians, one approach is to focus on the most wasteful practices, which he mentions. These wasteful practices show up in income for the system, some of which goes into physician pockets. Hence, it is worth pointing out how much physicians make.
    I would add that most of the huge disparity between physician incomes in the US and other nations comes from higher fees and higher utilization specifically of the more expensive “bleeding edge” treatments, not from higher utilization for basic things. Other nations are, if anything, higher utilizers for basic care.
    I do agree with MD as HELL, of all people, that we fetishize medical care too much and go to doctors for things we shouldn’t, and have expectations for care when we really should re-prioritize where scarce dollars should go.
    Conversely, we pay way too little attention to preventive self-care that doesn’t involve doctors (hello good nutrition and physical activity).
    For those wondering what insurers are “sacrificing,” watch what happens in the next 5 years on health insurer admin costs. They will be very significantly standardizing and streamlining their claims systems and forms, and the passage of the health reform bill will standardize benefits more than they are now (still will be complicated, of course, but less so). Billions in admin costs will be saved as a result.

  19. Another non physician taking shots at doctors making us the villians in a “crisis” that has a lot more non-clinicians being the profit motivated causes to the expenses at hand. Well, maybe a lot of doctors are just too kind or reluctant to call it as it is, but everyone is the damn doctor these days and knows better than the clinicians how to diagnose and treat people, thanks to this medium I am commenting on now. The time to be nice and PC is over, people, and I am calling it as it is: you want to let politicians, bureaucrats, and businessmen set the definitions to future care needs? Well, then have them treat you, as I am fed up with posts like this arbitrarily quoting incomes and agendas by doctors. Yeah, some people make obscene amounts of money providing care, but I bet if you break down those high income numbers, it is not all just patient care alone. Let’s be honest, a lot of surgeons have other investment factors that get listed as care income, and it isn’t in the end.
    I’m a psychiatrist, I have never seen close to 200K a year having practiced for more than a decade, and not because I underprice or minimize my income potential. I don’t need to pursue bucks first and patient care quality second, so to authors like this who paint a black and white picture about clinicians and their incomes, find some grays to your palate, please!
    And I am beginning to wonder what is the point of this blog site, is it health care driven or health care bashing driven? Readers, think about it!

  20. Patients need to request leaner medicine. They need to quit whining and accept some risks and uncertainties.
    Employers need to stop requiring a “doctor’s note” to excuse a work absence.
    Nursing homes need to not send every minor fall to the ER. They also need to not send Do Not Resuscitate patients who are dying a natural expected death.
    The only way any of this happens is for the patient to weigh the costs to them against the benefit to them. The only way that happens is for them to pay for the service, not just file a claim. Even if it was a covered event, the patient should front the money and receive the check from the insurance company.
    There would be a revolution in claims processing if the patient and not the doctor was waiting for the money.

  21. “…most stakeholders in health care reform — the drug companies, the insurance companies, the medical device companies, taxpayers, Medicare beneficiaries — have been asked to give up something to insure the uninsured.”
    Is that really true? Whatever the various companies are “giving up” is going to trickle down to the consumer in the form of increased prices.
    In any event, the CEOs of those companies and their staff will not see any salary cuts to help cover the uninsured.
    It would be nice if physicians voluntarily agreed to practice leaner medicine, but it’s not very likely. Changing the reimbursement models to encourage accountability is a much more realistic proposition.

  22. The AMA supports the current reform effort because it promises to shift money from specialists to primary care, and the AMA is dominated by primary care. It’s simply about the money.
    These figures are W-2 income figures.
    “Wasteful”, according to current wisdom, is defined in contrast to those areas of the country that consume less dollars per patient with equal or better health outcomes. This is all highly dependant on the Dartmouth research. The working political assumption is that 20 or 30% of care is “unnecessary”, because it is not being performed in the more “efficient” centers.

  23. Individual with this level of income are in the top 5% or so of all wage earnings in the US. No problem, but I find it hard to believe that the AMA supports a government run health plan knowing (I hope) that such incomes could not be sustained under such a system. Look at physician salaries in France and other countries with government systems.

  24. Since most doctors are not paid a salary, it would be interesting to know exactly what these numbers represent.
    Are they practice income or net out of the practice? Do they include the value of pension contributions or other benefits that may be paid by the practice?
    Exactly how does one equate these numbers to a person on a salary?

  25. Not sure it matters to anyone here, but the data for Orthopedics is 424k – 640k, not what is presented. The 640 is ortho spine surgeons, and neurosurgeons seem omitted from the list. Of course, they’d be at the top if they were included.

  26. I am a bit confused as to the point of this post, on one hand you raise the excellent suggestion of highlighting ‘waste’ from specialists (though I would extend this request to primary care physicians as well), but then suggest perhaps that the salaries paid to the top specialists are ‘waste’ or contribute significantly to the current health care crisis?
    It will be very difficult to identify ‘wasteful’ practices without standard definitions of what constitutes ‘non-wasteful’ practices. For example, ask a cardiologist, vascular surgeon and vascular medicine physician how to manage claudication and you may get three opinions as to what constitutes ‘wasteful’. Is it wasteful to screen women aged 40-50 with mammography every year? Is it wasteful to obtain head CTs on every kid with minor trauma (ie concussion)?
    I wholeheartedly agree that somehow tying reimbursement to quality and breadth of appropriate practice should figure into fair compensation. However, should we not also consider time and lifestyle commitment factors, hours on call, malpractice risk, length of training and schooling, patient load….? How would you propose to value the ‘worth’ of a physician currently practicing in the US?
    These are all suitable questions to ask, the problems is however, who will answer? How the concept of salaries fits into this I am not quite sure.

  27. Wow… doctors make that little…. why would you go into medicine… Entry level Wall street jobs make around 500K and you don’t need spend that much time in school.

  28. Cardiology society just sued HHS Sebelius for cuts in Echo and stress nuclear that are upcoming. Why did not Primary care not do this a decade ago when the cognitive skills were undervalued year after year. I am really puzzled as to why Hopitalists who can play a central role for In Patient care take such a passive role in their compensation. They are worth much more. Cardiology always lobbied for higher compensation and guard their income fiercely. If societies are playing politics at every step, will there ever be any common sense that can weed waste anytime soon, one man’s waste id other man’s income afterall.

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