Would I Quit?

By , MD

I love being a doctor.  I like my patients (most of them), and have had a pretty good career.  One of the things I say to my older patients is that I want to keep them well enough so I can see them at my retirement party.  I just turned 48, so that would be 17 years… give or take.

Given what I have been reading lately, the “takes” may be getting the edge on the “gives.”  Apparently the department of justice and the FTC are getting active in the scrutiny of doctors.  From the Christian Science Monitor (via Dr. Wes):

This case is a watershed for two reasons:

First, until now the Federal Trade Commission, not the Justice Department, has taken the lead in prosecuting physicians. Since 2000, the FTC has brought about three dozen cases against physicians (all but one of which settled without any trial). But the FTC only has civil and administrative jurisdiction; the Antitrust Division has civil and criminal jurisdiction. The Sherman Act makes no distinction between civil and criminal “price fixing,” so in a case like this, it’s entirely a matter of prosecutorial discretion whether to charge the doctors with a civil or criminal offense.

Based on the descriptions in the Antitrust Division’s press release, there’s certainly no reason they couldn’t have prosecuted the doctors criminally and insisted upon prison sentences — and there’s little doubt such threats were made or implied to obtain the physicians’ agreement to the proposed “settlement.”

The second reason this is a landmark case is that the Justice Department has unambiguously stated that refusal to accept government price controls is a form of illegal “price fixing.” (Emphasis by Dr. Wes)

The FTC has hinted at this when it’s said physicians must accept Medicare-based reimbursement schedules from insurance companies. But the DOJ has gone the final step and said, “Government prices are market prices,” in the form of the Idaho Industrial Commission’s fee schedule. The IIC administers the state’s worker compensation system and is composed of three commissioners appointed by the governor. This isn’t a quasi-private or semi-private entity. It’s a purely government operation.

What’s more, the Antitrust Division has linked a refusal to accept government price controls with a refusal to accept a “private” insurance company’s contract offer. This lives little doubt that antitrust regulators consider insurance party contracts the equivalent of government price controls — and physicians and patients have no choice but to accept them.

I must confess that my ADD makes reading legalese impossible (with out the use of a triple Ritalin latte), but the implication of this seems to be that I will be forced to accept what Medicare pays, and that contracts based on Medicare rates will follow suit.  I have also heard it told that lawmakers are considering making acceptance of Medicare a requirement for licensure.

This makes me ask the question: what would it take to make me quit practice?

Let me emphasize that when it comes to job satisfaction among PCP’s, I am at least in the top 25%, if not 10%.  When people ask me if I would recommend medicine, I enthusiastically say I would.  At least I have in the past.  I love the job – I don’t think there are many better.  But given the very small margins we work by in primary care, I am terrified by these possibilities.  I am a small businessman (no, I am not small; my business is small) who is providing a service and charging for it.  I get dragged around with a hook in my mouth by insurance companies and by government payors, but I do so by choice.  I stay in it, but I always know I can dump them if I choose.

These actions would change everything.  I don’t know why people would do one of the most taxing and responsibility intense jobs with the government forcing me to do it cheaply.  It makes me furious.  It makes me terrified.  It makes me consider studying homeopathy and selling herbs for huge profits.  OK, not the last one, but the non-regulated nature of the CAM providers makes me envy their control.  Yes, I am actually starting to envy CAM providers.

I am sure I am not alone in this.  I go home tired every day – emotionally drawn out by the emotional energy of propping up people’s lives, comforting their pain, and working to help heal them.  It’s a very draining job, but it is also very rewarding.  If primary care doctors are not allowed to be payed in accordance to their true value (the ones who actually save money for the system), the healthcare industry will be in deep trouble.  The patients would be in deep trouble.

Yo, politicians: we are dangling out here.  You are playing political chicken with our futures with the whole SGR issue, but so far you haven’t scared me off.  We are having the weight of reducing cost put on our backs and are then we may forced to eat the gruel HHS serves out.  Don’t do it.  We are not evil.  We are not in a conspiracy to steal money from the government.  It’s not about my Lexus (I drive a used Honda).  It’s not about my golfing holidays (I don’t own clubs).  It’s not about a cushy retirement (I won’t go there, but let’s just say that I have a lot of work to do in that area).  It’s about whether or not I will be around for my retirement party in 17 years.

I may just be selling herbs.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.

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17 replies »

  1. “Ever see the pics online of John Edwards’ house in Chapel Hill?”
    Got a pic of your house MD? Paid it off yet?

  2. My PA’s make 80-110k per year plus benefits. What doctor is going to train for 6-10 more years and work for 150k? Get real.
    Last time the AMA agreed to save the system money was 1983 when the voluntary fee freeze was used to trap docs into a lower physician fee schedule from Medicare. You cannot bargain with the devil.
    My new 2009 college grad daughter with a bachelors degree makes 62k plus benefits a year with a large computer company. She toys with the thought of going to medical school. Why in the world would she want to do that and give up promotions and raises?
    jd clearly resents doctors.
    Everyone else can collude to fix prices but not doctors. The doctor’s only choice was whether to work for the available reimbursement. Now there will not be any choice in that either? Now the private insurers will have hobnail boots provided by the government?
    A doctor slowdown will be quite effective.
    The last attorney I had to retain cost $400/hour. That is what I charge for expert witness testimony. More money there than doing CPR. Less paperwork, too.
    Theft is still theft. Legal theft is not moral just because it is legal.

  3. I think doctors are just now learning what every other industry has had to cope with — autos, retail, hospitality, widget-building. It’s a Wal-Mart world. We all have to buckle down, work harder, faster and better to compete for the same resources, because if you’re not willing to, there is someone out there who is. Someone bigger, faster and better, or perhaps just more desperate, will wring out a penny or two or 1,000 more in efficiencies that will allow them to eat your lunch.
    So Dr. Lamberts, a good man and a good doctor by all appearances, has his breaking point, a price below which he will not work. So do we all, no harm in that. Unfortunately, there may be 10, 500, or 10,000 others in the same field who are younger, less leveraged (not implying that Dr. Lamberts is, just making the point), or more energetic, and will work for that price.
    No one disagrees that doctors shouldn’t be fairly compensated for their work. Nor, I think, would anyone disagree with a system of bonuses for doctors who, as Dr. Lamberts calls it “save the system money.” Could not the AMA and the specialty societies agree to a simple set of metrics that do “save the system money” and a single dollar figure that every patient — regardless of the payor who carries them — should command for the various services provided? And couldn’t providers collectively agree on this package, present it to CMS and/or negotiate to some reasonable facsimile, and say, this will yield peace and stability?
    Yes, I think those things could happen. And in some localities, those kinds of things already are happening.
    But there’s always one or 10 or 100 spoilers who think their patients are sicker, their work is better, and they deserve more, isn’t that right? A couple of them even show up on occasion here at THCB.
    We’ll solve this problem when providers get together collectively and agree on one set of standards that payors (including tax-payors and us premium-payors) can live with that doesn’t have a whiff of the proverbial “free lunch” about it. Until then, we’ll muddle through with this unfortunate adversarial system.

  4. So, if working 65 hour weeks for $150,000 a year isn’t worth it (or whatever the exact numbers are for Dr. Lamberts or any other PCP), then what would be? What if you cut down on your practice and saw 2/3 of the patients, working 40 hour weeks for $100,000 a year? Why does it have to be all or nothing?
    I will not be surprised if medicine, like prostitution, turns out to be harder to quit than one thinks. Hard to turn down the good money.
    But I know this isn’t just about money, it is also about control and status. Not that this makes physicians more sympathetic to working stiffs.

  5. In my undergraduate years I decided to take the pre-med track, in hopes of becoming a primary care doctor. Instead of going to med school, I decided to pursue a Masters in Public Health to work within the health care system and focus on preventative care and one day be involved with policy to aid primary care physicians in their work. I agree with Dr. Lamberts in that primary care physicians dont get payed as much as they do for the work that are responsible for. It’s clear that Dr. L does it for the love and not for the money…very hard to find physicians (or med-students) with that focus.
    Keep doing what your doing, Doctor…we need more physicians like you.

  6. Nate is correct.
    This is not the end-of-the-world scenario that Dr. Wes and others would like it to be.
    It is just another restatement that doctors cannot collude to fix prices. We’ve known that for decades.
    Workman’s comp is a strange situation, in which there is truly only one customer (in this case, the Idaho Industrial Commission) and they can say how much they are willing to pay. Nothing in this ruling says that the docs are forced to see those patients.
    The issue is why are insurance companies allowed dominate markets and fix prices. Hint: Ronald Reagan had a lot to do with that.

  7. There is no liticare or liticaid. And plaintiffs are selected by lawyers who work on contigency fees. This means they are financing litigation which is supposedly unethical,but oh well.
    Ever see the pics online of John Edwards’ house in Chapel Hill? Plaintiff medmal fees pay better than saving lives.
    It has become politically expedient to claim to recover fraudulently paid out funds. There are so many opportunities for coding errors and so many grey areas in medical documentation that all of us can be picked off. Bite too many docs and all of us stop playing in the swamp.

  8. The biggest issue for me is not the DOJ action, it is the idea that I cannot have a licesnse without accepting Medicare/Medicaid patients. THAT would undermine all morale and drive many physicians out of medicine.
    Peter: the reality of it is what Andrew wrote. What is totally demoralizing for us physicians is that our system rewards bad work and we are going to be forced into that system, holding our licensure as physicians hostage to accomplish that task. Physicians like myself and Andrew are more the solution than the problem, yet we will take the bulk of the hit. We are not willing to prostitute ourselves out by opening “diet clinics” or giving botox injections. We are not willing to run people through the mill and see 50-60 patients per day to make up for our lousy reimbursement. We are trying to make our patients healthy and keep them that way. What’s our reward for that? An iron collar around our necks attached by a chain to the bureacrats in DC.
    It’s a terrifying thing. I predict that the exodus that will happen by doctors – especially those unwilling to compromise – as we are increasingly held as scape-goats for a problem others created, will cause the system to collapse. It is not just a bad idea, it is a cyanide capsule the government is forcing into the mouth of Americans. It would be tragic.

  9. “These actions would change everything. I don’t know why people would do one of the most taxing and responsibility intense jobs with the government forcing me to do it cheaply. It makes me furious. It makes me terrified.”
    Looked around at the general economy doc? You’ll see people forced for survival sake to accept a fraction of their former income or work more for same or work more for less, or work part time, etc, etc. I think docs still have it pretty good as I’m not seeing many in the unemployment lines.

  10. They make pretty clear the issue was the collective nature. If all the insurance companies got together and said lets all kick Doctor Y out of the network unless he accepts these fees I assume you would take issue with that.
    Everything the doctors did was acceptable if they had dopne it individually. Colluding to shake down the market is something that needs prevented from eirther side.

  11. I just don’t get how a column like this is printed after someone else previously champions for price fixing and mandating salary incomes for doctors. You could reply this is giving readers a diverse view, which I acknowledge up front is a great thing, but, is this column just offered up as a sacrifice to appease the critical commenters who are not accepting of the general theme at this site of “do as we say, not as we do”.
    I think what you write is beyond on the mark, Dr Lamberts, it is the reality the majority of responsible and caring physicians should be asking themselves and their colleagues NOW! You read how Obama and his circle of cronies are trying to buy off opponents, and it just makes you want to projectile vomit on these frauds of representatives! And this is the same guy, Obama, championing for health care change?! Excuse me, does anyone else reading and commenting here believe in the adage “deeds not words are what define us”? You want to put your faith and stock in this guy and his minions who are just as textbook in irresponsible and uncaring leadership as the Republican predecessors? If you answer yes, you deserve the representation you champion and vote for!
    Back to Dr Lamberts’ column here, after reading Jonah Goldberg’s column yesterday commenting how the Israelis get demonized for anything and everything they do to protect themselves, not that last week’s raid on the flotilla was a wise and productive incident, it does for me draw parallels how physicians are more and more demonized because we stupidly do not stand up and defend these more often baseless and reckless accusations we are the primary villians to the ongoing health care debacles at hand. And now you read how yet again government will change the rules to suit their twisted agenda.
    Well, I have said this for years, and it still applies now: Let them come after all of us as an antitrust violation and do what, jail us all?! Certainly benefits the public, eh, Obama, Justice Department, and other agenda makers? Throw the majority of doctors in jail, and then who is going to jump in and save the day? Politicians, the Maggie Mahars spokespeople, Nurse Practitioners without MD supervision, hell, people reading about illnesses off the internet treating themselves?
    If you have gonads, colleagues, when do you say when? At the end, when one foot is already off the cliff edge? When do we stop answering to people who are not legitimate peers and have no business setting precedents and principals they themselves do not answer to as well? Why is this profession shooting itself in the abdomen? Are we out of limbs to sacrifice!!!

  12. As a patient I see both sides. Andrew makes a great statement. People would pay $10,000 or more for breast implants and then complain that it costs that much to give birth to a child.
    Something is definitely wrong with that.
    However, it also shouldn’t cost me $10 for the use of a 20 cent cotton swab!
    Where is the median?
    I also hate that lawsuits are ruining doctors’ lives. I have six children and for my last child I had troubles finding an OB because they all quit due to liability insurance.
    Many things have to change in the healthcare industry from the mindsets of patients and doctors alike.

  13. Wrong idea. Medical cosmetics is where it’s at. It plays off of the baby boomers getting old and it’s a cash business. Since medicare doesn’t pay for any of it, you get to set rates based on what the market will bare, a novel idea in medicine.
    As a cardiologist, when I see “colleagues” getting paid more for a few botox injections than I do for discussing with a patient (and his family) whether or not replacing his/her aortic valve is in their best interests, I start getting depressed when I think about how truly perverse our system has become

  14. Hmmmm. I vote for the homeopathic route, but there is no money in that. It is a shame that we have settled for the easy way of things. Notice I did not say the best. For years I pumped drugs into my system. Short term fixes at best, but my quality of live went down the tube. I just found your blog and I like your style of writing. I will continue to read.