Why do you complain so much about residency and medicine? It’s not as if you, personally, can do anything about it and besides, aren’t you done with call and most of the other less than savory aspects of medical training?
Like I always tell people, this blog is not about validating any particular point of view (except mine, of course). I call them like I see them using the occasional foray into satire to highlight what I regard as some of the problems of medicine and medical training. Do I expect that my blog will have any effect on the great storm about to break on us all? Of course not. I am just one guy with a little blog on a little patch of hard drive somewhere on the internet tundra and my thousand or so visitors per day hardly make a stir in the vast expanse of the medical world. Still, change is coming. You can feel it in the air. The frustration in the medical profession hangs thickly around us and I am not the only physician to sense this.
What are some of the Frustrations?
They are legion and one hardly knows where to begin but malpractice has to be at the top of everyone’s list. Protestations of various oleaginous lawyers and policy experts to the contrary, litigation and more importantly, the threat of litigation has a profound impact on how medicine is practiced in this country and its increasing cost. While the actual cost of payouts in malpractice suits is fairly trivial compared to the huge amount of money changing hands in the medical industry, the behaviors engendered by the threat magnify the cost tremendously. Can I quantify the percentage of care we deliver that is wasted on so-called “defensive medicine” (that is, medical practices designed primarily to protect us from frivolous suits)? Of course not. One man’s defensive medicine is another man’s justifiable dilligence. On the other hand as I have eyes I can see that we spend a great deal of money in the hopeless quest for perfection, perhaps the worst place to spend money as the incremental increase in health this buys us is hardly worth the tremendous cost to achieve it.
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The fact that I can’t put an exact dollar figure on purely defensive medicine does not mean that there is no problem. Certainly the impact is greater than the combined cost of malpractice insurance and lawsuits and just as certainy if we killed all the lawyers and allowed common sense to work its way back into health care we would save a lot of money in the long run.
Common Sense?
In a perfect world, the public would accept that medical care entails risks and the money we spend protecting them against unlikely consequences would be better spent on medical care that makes a difference. Somebody pays for the drunks that detox in the Emergency Department rather than the police drunk tank, for example. Maybe it’s hard to quantify the cost but protecting these patients from the unlikely risk that they will aspirate vomit takes staff and facilities out of service for other productive medical uses. And the money spent on exclusionary workups which have little to do with the chief complaint has to come from somewhere. Since very few people actually pay for their medical care directly and physicians are under a great deal of pressure to avoid getting sued, there is no organic incentive for anybody to think about cost.
Which leads to another frustration for physicians, namely that while on one hand non-medical adminstrators have increasing influence on how doctors practice, they are not exactly sharing the liability. It is perfectly reasonable, for example, for an administrator to try to curtail the use of expensive studies where they are not indicated. On the other hand the administrator doesn’t provide much cover for the physician who knows perfectly well that he can practice perfect evidence-based medicine and still be dragged through a malpractice trial in which his professional reputation,livelihood, and assets are put in jeopardy.
Yeah, but aren’t doctors just complaining a little too much?
Well, everybody complains about their job. And everybody has to deal with the bean counters. But as the economics of medicine are often at odds with the practice of medicine, there is an adversarial relationship between doctors and the accountants. As I said, controlling costs is perfectly justifiable and in a perfect world we would know with certainty how much to spend on every patient. However, even without the uncertainties of defensive medicine, it is not possible to fit every patient into check boxes and standard forms. Sometimes we have to write outsides the allotted area. That’s sort of the point of having physicians and not self-service computer kiosks where patients enter their symptoms and receive exactly the treatment they need with no wasted effort or money. Now, it may come to that in the future as mid-levels and lower level providors are pushed into the breach to stem the onslaught of the aging baby-boomer hordes, armed as they are with their horrific powers of entitlement and inevitable “free” health care, but the public is going to suffer. Not that most will care or know the difference. They will be getting substandard but free health care. Huzzah!
Besides, physcians with their extensive education and abilities are always a convenient scapegoat for politicians looking to redirect the anger of the mob.
Paranoid, aren’t you?
Not at all. But it is easy for anybody looking to curry favor with the electorate to attack physicians. The public believes that we are all multimillionares without a care in the world and, as a class, too smart for our own good. Disliking someone who is wealthier and smarter than you is a primal urge very common in both the trailer parks and the halls of academia, two disparate places that never-the-less share some of the same provinciality and the overbearing confidence of ignorance.
The fact, for example, that even the lowest paid physician generally has to struggle through at least seven years of exhausting training and that he might just be worth his salary never occurs to either group.
Another thing that should bother everyone in the health care industry is the concept that health care is a right and needs to be provided for free. The insanity of this concept is obvious. Rights do not have to be provided, they exist independently of governments and while they must be occasionally secured by either war or revolution, they are not a commodity to be provided to the public. Nobody’s has to work a twelve hour shift at the Department of Free Speech to keep the dissent flowing.
Medical care, on the other hand, is a service provided by people who expect to get paid. And will get paid except for doctors whose compensation under inevitable government run health care can be legislated as low as the congress thinks it can get away with. What are doctors going to do? Go on strike? Of course not. We’ll just suck it up because our ethos forbids us to harm, even by ommission, any of our patients. Nurses on the other hand wouldn’t put up with an attack on their salary for a minute and as a group, know how indispensible they are and leverage this effectively. And they have pretty good juice with the public. Imagine a suicidal politician proposing that nurses and other hospital workers need to accept less pay for the public good. That man would be tarred, feathered, and run out on a rail.
Money, money, money! Is it that important?
Of course it is. Money drives everything. Even your disdainful college professor preaching the gospel of poverty can only do so because he has waged bureaucratic war for his tenured position, a position which may not pay as well as some other careers but one from which it is almost impossible for him to be dislodged and which provides enough income for him to turn his nose at other people’s money. He’s not working for free and neither does anyone else. This is not a bad thing, either. Societies that try to do away with the individual profit motive are dreary, impoverished places because what works in a small commune or a kibbutz cannot be extrapolated to an entire nation. If there is no benefit to working hard, and no risk in not working, the freeloaders, Alexander Zinovyev’s famous “Homo Sovieticus,” tend to take over.
So the disdain for money is fairly unhealthy even in the medical profession. There has to be an incentive for people to work hard and long. You will always have people willing to be physicians of course, but their enthususiasm for seeng that extra patient or coming in from home to operate on a patient on the weekend will diminsh as the rewards for doing it evaporate. Medicine is a rewarding career independent of money but it ain’t that rewarding. It can be something of a grind as I’m sure many Family Medicine physicians would probably tell you after their thirtieth patient of the day.
Speaking of frustrations, there is probably none bigger than the way physicians are reimbursed. The system is crazy and I have only had a small taste of it. They call medicine a business and patients customers but it’s a strange business with the oddest customers and that’s no lie. (Is medical care a right or a customer-driven business?) First of all, many of our customers not only don’t pay a dime but the very idea that they should have to pay even a fraction of the cost of their care never enters their heads. If medicine were a business this would be called theft. At least shoplifters know they are stealing and try to hide thier crimes which is not the case in the medical world where a family will boldy stride into the ICU and insist that we spend whatever it takes to squeeze a couple more days out of their demented, stroked out, septic, octogenerian grandmother. It’s somebody else’s time and money, what do they care?
On top of this, attached to the most technologically sophisticated industry in the world which performs commonplace miracles that would have been inconceivable just fifty years ago is a system of remibursement straight from ancient Byzantium. A nice system for a courtier, a eunuch, or a lawyer but as adminstrative costs alone are said to gobble up a third of every health care dollar, money that provides no medical care whatsoever, what exactly is the benefit to the public and how can doctors be blamed for the high cost of health care?
It’s not a problem that has an easy solution. The single payer zealots opine that making government the insurance provider will streamline things but all you’ll really get is a clumsy bureacracy looking for ways to not reimburse and holding onto every penny like it was a gold coin. Very similar to a private insurance company except that Aetna cannot kick down your door and raid your house. Insurance companies need to make money for their stockholders. Governments try to dole out scarce money to constituents to buy their votes and there is never enough to go around.
But hell, the public doesn’t care. They want medical care for free no matter how much it costs. We are already conditioned to not care about the price of health care. Very few people actually take out their wallet and pay for even something as simple as a routine doctor’s visit that in an ideal world would cost eighty bucks and, in a country where people pay twice that for a month of cable television, would be considered a good value for the price.
I don’t think we need to do away with insurance but we need a simple law forbiding hospitals and clinics from billing a patient’s insurance company. Especially if it is the government which, along with private insurers, currently pushes the greater share of their administrative overhead onto health care providers who receive no extra money for their troubles. In the old days patients paid their bill and then submitted their claim to their insurance company. Watch how fast things would tighten up if patients were refused reimbursement for the same reasons that doctors are currently refused. You’d have angry patients, angry both at the government and at doctors for not caring about how much things cost which is probably the greatest incentive there is to efficiency and reasonable prices.
(To Be Continued…)
The funny thing is I went to the doctor today and paid out of pocket without even thinking twice about it. I’ve always failed to see how paying your damn bills is such a hard concept, and unless something drastic changes, I don’t think I’m going to understand the shoplifters of medicine anytime soon.
If patients used to pay out of pocket and then ask their insurance companies for reimbursement, then I agree we need to go back to that system. Not only will doctors not get stiffed as much, but patients (mostly the young, healthy ones) will quickly learn how useless insurance is and how much of a waste of money it is, and just stop having it. Either that or make it a felony to intentionally not pay a medical debt.
Amen. It would make things more irritating if patients were constantly considering the price of things, but I can’t even imagine how much it would drop a lot of the useless things and CYA we have to do.
“Yes, you will receive a 2k bill for MRIing your son’s bruised shin. However, you did demand ‘absolutely every test’, so this is what our lawyers are prepared to offer.”
A 20-year-old stopped me in the hallway of the hospital this week to ask me why his mother’s medical team won’t give her a full-body CT scan and MRI to rule out metastasizes from her breast cancer. Although the woman was not my patient, I tried to explain to him that (1) the pathology results were not back on the lymph node dissection and (2) the tests he wants will run several thousand dollars, come with additional risk to the patient, and tie up the machines so that others cannot use them. He replied, “Well, in a perfect world, wouldn’t cost not be an issue?”
Thought experiment from one who has played the game very successfully for twenty years and is beginning to weary of it. What would happen if you instituted these two simple principles, neither of which will occur because they upset the stakeholders too much:
1. No third party billing
2. Loser pays liability
Comments?
What do you think will happen to doctor’s salaries and other para’s (i know what you think about the nurses) if/when Universal HC comes into being?
Will the big insurance lobbyists be able to stop Universal HC?
Being a pharmacist, I’d LOVE to see people foot their own prescription bill. It’d greatly reduce my pharmacy’s burden of dealing with insurance, prior auth, step therapy, etc. I know the local physicians around me wouldn’t mind it either. More time for pt care, less in administrative redtape. In fact, I have fellow classmate of mine who has opened a generics only pharmacy, accepts no insurance whatsoever, and is completely happy. He also makes more than I do as a pharmacy manager for a busy chain (current $129K). BTW, Panda, your blog cracks me up. Keep up the good work.
I’ve been helping my 45-year-old sister-in-law with her bills/EOBs from a recent 5-day stint in the hospital wherein she had an L5-S1 fusion with instrumentation (both anterior and posterior approach). The surgery lasted 4-1/2 hours and while I don’t have all of the exact information yet, I believe the ortho surgeon didn’t perform the anterior approach all by himself (they usually don’t).
The orthopedic surgeon’s bill ALONE was $130,000.00. The total hospital bill thus far is $300,000.00. I don’t think we’ve seen the anesthesia/anesthesiologist’s bill yet.
I don’t think it would **ever** be possible for a person to be able to pay out of pocket for this.
As an aside, she did try everything in her power to avoid the surgery, 3 ESIs, radiofrequency lesioning, PT, etc.
I really like the idea of making the patients responsible for seeking reimbursement, both because it would allow physicians to focus less on business and more on medicine and also because the public might actually realize how difficult it is to get reimbursed by “the great satan.” Surfie brings up a good, though; in a case where the medical bills are really big, could the patient maybe pay their bill in installments? It’d be like paying for a car…only a car that has been surgically fused to ones spine. Just a thought.
Keep on belting it out, Panda. You make a difference (I think).
Heh..FaultyBeanCounter,
I’d say it’s more like having a jet airplane fused instead of a car!
Bravo! Great post. I actually think that your idea of making patients pay the bills and then having them deal with their insurance companies would solve quite a few problems.
Surfie: While it’s regrettable that surgeries do cost quite a bit, I think think Panda’s point that healthcare is not a right is well-founded. If your sister-in-law purchased insurance and the company covers this surgery, then she has paid for the operation as part of her contract with her insurance company. I understand that you mean that Panda’s idea won’t work if people have to fork over $300,000 before reimbursement and I agree. It could, however, work if patients are forced to get pre-approval and pre-payment from their insurance companies before the operations will go forward.
Problems arise, however, when someone has no insurance and requires a surgery. Then the person must find a way to pay for the surgery (and would probably be best off negotiating rates with the physicians and hospital beforehand). Surgeries require time and resources and no matter how great the need, they should never be thought of as a right. If the surgeons and staff and hospital want to donate their time and resources, that’s fine. It’s when patients choose to undergo procedures and then don’t pay when they’re billed that we leave the realm of charity and enter the realm of theft. So, healthcare providers should not be forced to provide care to anyone for free (unless they choose to).
Panda before has pointed out that very expensive procedures like the surgury mentioned above are exactly what should be covered by insurance. Just like home insurance in the case of a house fire.
In several posts on my blog I’ve made mention of the pervisity of a system of medical reimbursement that takes no account of excellence. The reimbursement, for example, for a colon resection is the same when done by Dr A, B, or C, regardless of whether one dones a demonstrably better job than another. Whereas doctors don’t, in general, go into it specifically for the money, the good ones have an expectation that hard work and excellence will be recognized. For better or worse, money is a talisman of recognition. To the extent that the system is, to a continuing extent, failing to recognize that, it’s inevitable that it’ll select against those with the ethic of hard work/excellence/reward. It already is.
yikes. The word I meant is “perversity.”
We can already see fragments of what the future will surely hold. In a world of salaried, no-incentive-to-work-harder physicians, you will be assigned a doctor. You will not be able to switch because no one else can get paid for your care. Today you see Dr. X, then next time Dr. Y, then later you find that Drs. X and Y have left the practice, so now it’s Dr. Z, who may or may not speak English fluently.
If you call about something urgent tonight, you get to listen to a machine that, after several key presses selecting various options, tells you to either wait until regular office hours or go to the ER, your choice.
You see Dr. Z at the mall one day. You mention a concern to him, he says, “I’m sorry, I’m not working. I can discuss then the next time I am working, but if you need an answer now, call the office, and nurse practitioner Q may be able to answer it.”
Panda,
would you mind if I copied and pasted some of your work into an e mail to my state congressman?
(I don’t mind. But it won’t do any good.-PB)
Pervisity and moral hizard….
Panda,
If you keep this up, you’re gonna make my blog obsolete.
Keep up the good work. I’m perpetually impressed.
Sid Schwab: Tying reimbursement to outcomes is exactly what the government and insurance companies are doing today. That concept is pay for performance (P4P) and although it has the incentive to push physicians to maximize a favorable outcome (so that colon resections A,B,C, and D theoretically arrive to the same outcome), it does not push patients to be compliant with medications or follow-up appointments, nor does it entice every one to show up with the same exact anatomy and same exact pathophysiology.
Wouldn’t it be great if people were just like Hondas?
Bacteria also do not care about P4P. They are content with mutating freely, as well as ignoring the persistent requests of antibiotics. Neither of those factors are tied directly or indirectly to physician performance.
Surfie: while I am empathetic to the plight of your sister-in-law, the very fact that the medical bills were as substantial as they were, speaks to the perversity (see!) of the system that taxes those willing to pay their own bills, to also pay the bills of those who have no intent to pay their healthcare bill.
Imagine if cable TV could be freely received by anyone. Essentially, we’d have a ‘right’ to cable TV. Cable TV bills everyone, and only a tenth paid the bill in full. Half of the subscribers paid, but throgh a Cable insurance that only paid a third of the bill, and restricted which movies you could order and which channels you could receive. The rest simply did not pay the bill. Cable bills will quintuple in price to cover those that do not pay the bill or pay partially.
Healthcare responds in the same way to the shoplifters and Insurance companies. Want to reform healthcare? Reform should start there!
shockdoc: P4P is indeed a joke. But it’s hardly “taking account of excellence,” in the context of my post. Doing so would be a major endeavor, as I’ve described on my blog. P4P has little, if anything, to do with excellence. It has to do with filling a few boxes on a checklist. As you well know, and as do I. My point remains: if there’s no recognition of those who do a better job, and no effort to find out how they do it, sooner or later there’ll be no incentive for those who strive; they’ll go elsewhere, as they already — according to my friends in academic surgery — are doing.
I think it is interesting that because something CAN be done it is assumed that it MUST be done in regards to healthcare. As cold as this seems, and I wonder whether I’d be able to walk this talk, before modern medicine could keep people alive efficiently, when you contracted terrible diseases you died. Sorry, terrible luck really. Now that we can cure people have begun to see it as a requirement that we do, otherwise we are committing homicide by neglect. I hate to think of letting people die because they cannot afford the solution, but we let people die all the time because they cannot afford food, or shelter. It may not be right, but it isn’t a perfect world.
Just recently I had to cough up several hundred dollars for my pet’s surgery. I could have decided I couldn’t pay, there was no insurance, and put the pet down. It happens all the time. For many pets are “family” yet we weigh their lives against economics all the time in healthcare. Why, oh why, is it some evil to consider economics in a human loved one’s care?
Granted it’s easy to say now. If I were the patient my views might change. But, hey that’s life. I plan to the best of my ability, but nothing but luck lies between me and the reaper. When did death become such an unnatural phenomenon in America?
“He replied, “Well, in a perfect world, wouldn’t cost not be an issue?—
Um, in a perfect world, I’m pretty sure disease wouldn’t be an issue!
Great entry, as always.
“On the other hand the administrator doesn’t provide much cover for the physician who knows perfectly well that he can practice perfect evidence-based medicine and still be dragged through a malpractice trial in which his professional reputation,livelihood, and assets are put in jeopardy.”
This is just nonsense. There are too many physicians out there practicing with multiple malpractice payments for this to be true. And are there any physicians anywhere who have lost all their assets due to a suit? Even 1% of all those sued?
You say defensive medicine exists because you see it. Great – but nothing is going to change because 1, you can’t define it, and 2, short of outright immunity you’re still going to practice the same way, because if you royally screw up on a patient, they’re likely going to have a ton of medical bills to be paid which still result in a big judgment.
Perhaps medicine would improve if physicians actually accurately quantified the risks that have got them so scared.
You complain about the public’s perceptions on free medical care, as if it’s them who are signing the contracts with insurers and the government that dictate how you get paid. You, the provider, make those choices. Those choices result in a pretty fine standard of living compared to most Americans, but you don’t have to make them.
Don’t like the way you’re reimbursed? Don’t sign up with the entity. The public has these expectations on what they should get for the money because you keep taking the money in that form. You stop, and we patients will start looking around for something else because there won’t be any doctors on our insurance plan.
At the end of the day, physicians really have no one but themselves to blame for their reimbursement woes.
Yes, at the end of the day physicians do not have anyone to blame but themselves for the reimbursement fiasco.
Having said that, we have plenty of people to blame for the malpractice crisis- and it always comes down to the lawyers. Whether they’re hounding doctors or threatening them for the audacity of actually questioning one of their counterparts actions, we’re in a bind. The same lawyers that decry the repeat malpractice offenders (the doctors, that is) are the same lawyers who will defend the scummiest of those repeat offenders. We all know who the shysters in the medical community are. Just you TRY to do something about it and you’ll get sued a whole lot faster than if you amputate the wrong leg.
The malpractice “crisis” has still resulted in less than 5% of your overhead, not gross, being spent on malpractice on average. If you spent half as much time working on eliminating malpractice as you do fussing about lawyers, you’d be twice as successful at eliminating the risk.
And can you point me to those lawyers who represent plaintiffs in med mal cases and represent physicians before medical boards? I think you’re making that up.
Malpractice can easily cost a shitload more than 5% of your overhead. Depends on what you are doing. I don’t know about family docs and internists malpractice, but try to tell a neurosurgeon, ob/gyn, or anesthesiologist that their malpractice insurance only costs them 5% of their overhead. Ha.
And you are missing that point that Panda repeatedly has to make. Malpractice abuse => poorly quantifiable (but very apparent) defensive medicine => higher costs all around => things being too expensive
Putting aside the fact that Panda making a point doesn’t make it true, what’s the total increased cost? And if that’s true, why haven’t decades of “reform” made health care significantly cheaper in some states with “reform”?
How much would we save if we instituted his version of “reform”, whatever it may be?
(What reform are you talking about? Have we killed all the lawyers? Have third party payers been made illegal, that is, that patients themselves must submit bills to the insurance company or the government? Have physicians and surgeons providing free care as consultants in the Emergency Department been made exempt from all lawsuits except those for gross negligance in an extension of current Good Samaritan laws? Have people been required to pay for their own primary care? Have people gotten smart and realized that primary care is cheap and not worth the thousands of dollars it costs them every year for their whole life of paying for comprehensive health insurance?
I’m sorry, did I fall asleep and miss the government and the people deciding that all social programs would stress personal responsibility and we would no longer subsidize bad personal choices? Anybody? Bueller? Buelller?-PB)
Sorry, PB, I assumed with your incessant bitching you might have some solutions in mind. Didn’t realize it was just typical ranting. No wonder the single payer types have a leg up.
You’re right, though, we should kill all the lawyers. Doctors will stop committing malpractice if we do, and were they to be so accidentally careless, would be sure to volunteer to pay the bills of their victims.
You want people to pay for their own primary care? Quit accepting the money from the insurance cos. and the govt. Until you do, the public has no incentive to pay you direct.
You want them to respect primary care? Quit signing contracts with those health insurers you revile. What’s stopping you? Just yourself.
The main source of bad choices in healthcare reimbursement are those of physicans. Why does everyone else have to solve the problems of agreements you continue to enter into? You bad personal choices?
Anyone? Bueller?
In fact, many physicians opt for the so-called “boutique” practices, that is, where patients pay up front and the patient, not the doctor, deals with insurance. But these are the only physicians that have complete control over their compensation charging as they do what the market will bear.
On the other hand, I have no doubt that you, Matt, would scream and complain if every doctor did this. In other words, out of one side of your mouth you condem doctors for signing agreements with insurers and the government and out of the other you would attack those who opted out as greedy and sel-centered.
You seem to be advocating that physicians accepting medicare and medicaid, just another insurance company although this one can kick down your door in the middle of the night, should swithc to boutique practices.
Now, I happen to be in a specialty that sees everybody and where insurance is not an issue so I have a little less freedom to choose my practice style than most people.
In a single payer system, the government wouldn’t even give physicians the option to make a bad choice, by the way, because as soon as the majority of physicians decide to not accept the government dime they will iikely be forced to it.
The other question is, how much malpractice insurance do you pay and do you think it is reasonable and does the threat of litigation alter the way you practice?
“On the other hand, I have no doubt that you, Matt, would scream and complain if every doctor did this. In other words, out of one side of your mouth you condem doctors for signing agreements with insurers and the government and out of the other you would attack those who opted out as greedy and sel-centered.”
Nice move – You make up my position then argue against it. In lieu of actual debate, it’s not bad, although somewhat tired.
“You seem to be advocating that physicians accepting medicare and medicaid, just another insurance company although this one can kick down your door in the middle of the night, should swithc to boutique practices.”
I don’t care what you switch to. What I’m saying is that all your bitching about the way you get reimbursed doesn’t mean much when you keep signing the same agreements to reimburse you in the same manner. What incentive is there for anyone to change the way you are reimbursed? The only thing that is happening is that policymakers are hearing you on how “bad” everything is, so they’re casting about for solutions, and the only one anyone is seriously offering is single payer. So that’s what you’re going to get.
But again, if you all hate the way you’re reimbursed, why keep signing up for it? I don’t know, but I suspect that it’s because at the end of the day, it provides a damn fine standard of living, and most of you are loathe to give that up and take the risks of the true free market, where you actually do get paid by your patients.
As for whether the threat of litigation alter the way I practice, no. I try and do the best job I can for all of my clients.
Hasn’t anyone thought of just having one of those tiny electric cars for housecalls, do Scype office visits,let a website organize your housecalls and scype visits and have the
visits pre-paid electronically?
Have a good relationship with a lab and an independent imaging center. Get cozy with a GI guy, a pulmonologist, and a surgeon. Broker catastrophic insurance to your patients. Become a serious Christian, pray a lot, and tell the malpractice companies to go fuck themselves. Invest any money you make in untouchable places.
I’m about ready to become a medical journalist
or a ship’s doctor with the way things are going.