http://www.startribune.com/politics/national/congress/22708684.html?location_refer=Opinion
Recently there has been some squabbling over budget cuts to Medicare/Medicaid and state-sponsored health care that may cause doctors to decline services to those patients, because they won't be "properly compensated" by the government. So the doctors are revolting, and Bush has threatened to veto any cuts proposed by Congress. Right now they're debating a 10% cut, actually as part of a mechanism that was previously approved in the event that costs exceed certain markers, which is happening now in a big way. The pay cut survived the House, but will probably stall in the Senate and will definitely be killed at the Oval Office.
I know doctors are businessmen/women too, and they have a bottom line to maintain. They are skilled professionals who went through rigorous training ($30,000/year tuition + living expenses), and deserve compensation for their critical contributions to society. But I don't know how they can morally refuse to treat needy people dependent on government health care, just because they'll be reimbursed $2,700 for an arthroscopic knee surgery instead of the "going rate" of $3,000. Are they pinching pennies that much, even with a $200,000 salary? The cars they drive surely don't suggest it.
And what other industry but health care can the providers dictate costs and the consumers just have to accept it? Equally greedy HMOs and others might try to negotiate a "fairer" price, but in the end the doctors bill Medicare as they like, and our tax dollars go up in smoke (in many cases, overcharging Uncle Sam). In other markets like automobiles and air travel, competitors are cutting prices left and right in order to secure customers. But can we "shop around" for doctors who can provide the best service at the most reasonable cost? We just go where our insurance tells us to go, and actually most of the process is a black box to us. I guess most of us just feel lucky that we weren't refused care!
There was an interesting NYT article last year (below) discussing whether US doctors are paid too much, and whether they have more impact on the insanely high costs of health care than even prescription drugs. Pharmaceuticals are 30-50% more expensive in the US vs. Europe, but doctors' salaries are sometimes 100% more. A typical UK doctor in 2002 made $60-120,000 and lives well, if you've seen Michael Moore's "Sicko". But US specialists make $300-400,000, and we all know the young doctors graduating from school all want to be specialists. But how many radiologists and anesthesiologists do we need, versus the pediatricians and GPs who deal with normal patient problems and practice normal medicine "in the trenches" (ironically the lowest-paid doctors)? Relatively few new doctors are going into those "unglamorous" fields versus the huge demand, so no wonder we have to import them from other nations - yet some patients complain about foreign accents and demand an "American" doctor. Well, blame the American medical system and its students then, who would rather be Nip/Tuck than Patch Adams!
Because the fees they charge are so high (and patients have no choice but to pay), doctors also have a financial incentive to over-prescribe treatment in order to make more money. I am sure we can Google many examples of this to back up the NYT's claim, as well as cases of defrauding Medicare/Medicaid. And unlike Europe, Medicare lacks the resources (and/or motivation) to scrutinize a doctor's treatment request, veto if unnecessary, or maybe suggest a cheaper alternative. Doctors in other developed nations are more-or-less paid flat salaries from their national health systems, with performance-based incentives. Their doctors are paid less, yet deliver better services on average, based on WHO rankings and other studies. In fact, socialized medicine nations like the UK, Canada, and Australia outperformed the US in terms of medical errors and patient satisfaction (http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/tb/2074). So maybe there is a real problem with the "quantity over quality" approach by many US doctors.
From NYT:
"Almost all expenditures pass through the pen of a doctor," he said. So a doctor may decide to perform a test that costs a total of $4,000 in order to make $800 for himself — when a cheaper test might work equally well. "This is a highly inefficient way to pay doctors," Dr. Bach said.
Medicare, especially, does not like to second-guess doctors' clinical decisions, said Dr. Stephen Zuckerman, a health economist at the Urban Institute. "There's not a lot of utilization review or prior authorization in Medicare," he said. "If you're doing the work, you can expect to get paid."
As a result, doctors have steadily increased the number of procedures they perform on Medicare beneficiaries — and thus have increased their income from Medicare, Dr. Zuckerman said. But the extra procedures have not helped patients' health much, he said. "I don't think there's any real strong evidence of improvements in health status."
Private insurers like H.M.O.'s are more aggressive than Medicare in second-guessing physicians' clinical decisions, and they will refuse to pay for imaging scans or other expensive new procedures. Now Medicare and private insurers are moving cautiously to change the current system. Recently, they have proposed pay-for-performance measures that would give doctors small bonuses if their care meets the standards set by national medical organizations such as the American Heart Association.
BUT all those measures are a minor fix, said Dr. Alan Garber, a practicing internist and the director of the Center for Health Policy at Stanford University. Instead, he argues, the United States should move toward paying doctors fixed salaries, plus bonuses based on the health of the patients they care for.
Even in the existing system, some health insurers, notably Kaiser Permanente, already have large networks of salaried doctors. But it would require doctors to give up some of their autonomy and move into larger group practices or work directly for insurers, a step they have been reluctant to take. About 40 percent of doctors are in single or two-physician practices, Dr. Garber said.
Nor is the American Medical Association, which represents doctors, eager for wholesale changes in the system, said Dr. Edward L. Langston, chairman of the A.M.A. board.
But Dr. Goldman of RAND said that doctors are misleading themselves if they think the current system serves patients' needs. For example, if a diabetic patient visits a doctor, he said, "the doctor is paid to check his feet, they're paid to check his eyes; they're not paid to make sure he goes out and exercises and really, that may be the most important thing."
"The whole health-care system is set up to pay for services that are rendered," he said, "when the patient, and society, is interested in health."
Oh yeah, and I forgot to mention that doctors are often paid the same from insurance/Uncle Sam whether they perform a procedure brilliantly or totally botch it. Some legislation was proposed to only pay doctors in full upon successful completion of the procedure, but of course the physician's lobby fought it and watered it down. Now the government doesn't have to pay doctors for a few specific errors, like if surgical instruments are left in patients, catheters are improperly implanted, and won't cover the costs of preventable hospital-acquired infections. Doctors warned that such rules would cause legal nightmares and actually reduce overall care, as patients would have to disclose their entire medical histories before doctors would agree to treat them, so various post-op complications wouldn't be blamed on them. And then doctors might even refuse to treat the most at-risk patients to avert potential consequences. Well, I guess we shouldn't revere doctors as selfless heroes. They look after #1 just like the rest of us.
http://www.washingtontimes.com/news/2007/aug/28/medicare-and-medical-mistakes/
http://www.bcbs.com/news/national/medicare-won-t-pay-for-hospital-mistakes.html
So if our presidential candidates do seriously want to overhaul and improve the US health system, trimming doctors' salaries may be a politically daunting but absolutely necessary component of the solution.
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http://www.nytimes.com/2007/07/29/weekinreview/29berenson.html?_r=1&oref=slogin
The Nation
Sending Back the Doctor's Bill
By ALEX BERENSON
Published: July 29, 2007
