Surgeons get $30,000 to $50,000 for an amputation? On what planet?

Heard about the MD Congressman from Wisconsin who refused the federal government insurance unless it was available to his constituents? See: http://kagen.house.gov/index.php?option=com_content&view=article&id=446… Granted, he has the means barring catastrophic illness, but somewhat gutsy, nevertheless.

Yeah, in one of his appearances yesterday Obama also erroneously stated that the AARP had endorsed his health care reform plan. He was responding to a question about the ridiculous "He wants to kill your Grandma!" meme. Again, not even in the same league as the shitstorm of idiocy coming from his opponents, but if you know roughly half the country is trying to undermine you, why wouldn't you spend a little extra time on fact-checking? Of course the AARP had to come out and say "nope, no endorsement for us" (they want some sort of guarantee that generic alternatives will be made available sooner for expensive prescription drugs). There were plenty of real, true ways to rebut the 'death panel' nonsense, but now Obama just looks stupid, or misinformed. Damn.

the truth hidden in there is that the cost of amputation, etc, is higher than the cost of prevention...probably. Certainly the moral cost is higher for amputation due to societal neglect.

Honestly, as you said "professional fees, the construction of a prosthetic, and rehabilitation care" cost some where close to $30,000 is hell of allot more truthful then your "surgeon fee".

Yes, I would be going to the hospital to see a surgeon, but I'm not entering the hospital to write you a check and say "Well, there she goes, but I appreciate the help doc." No, I'm going to go there and pay for it literally for a life time and the kicker is... I probably never met the surgeon (or least can't remember while under sedation).

No, I think as far as seeking medical help is concerned he was being allot more realistic. He may have upset you with the wrong terminology, but he's speaking to layman. You're just a line item on the bill in reality.

Seems a reasonable mistake to me to confuse the total cost of a surgery with the surgeon's fee. Probably should have double checked his wording but not a big deal compared to the lies the opposition has been putting out.

hmmm... so Obama has said some things that are factually, realistically wrong. Perhaps those who interpret those things as a first step toward fascism (you know, that thing that led to nazism?) may not be as irrational as one might think?

Perhaps Obama is not the great communicator he is made out to be. Perhaps he's said other dumb things too. (Of course there's always the possibility that those stupid Republicans just mis-spoke. That's always a good excuse, isn't it?)

Just a thought.

I've called in the prescription for my anti-sarcasm drug (paid for by taxpayers, of course!)

Individual AARP officers have spoken against the "Death to Granny!" B S, and that has been taken by many (including the President) to be a blanket approval of the plan currently being argued over.

Let's get back to how you guys make mistakes all the time instead of quibbling over doctor profit and hospital profit.
The news story below talks about how doctors have been wrong about something for 50 years.

Just like they are wrong about masturbation making a person blind and crippled, the effectiveness of acupuncture, or human beings having energy.

Never trust a scientist. In 50 years someone will discover their "expert" knowledge was worthless. But only after making 50 years worth of patients suffer by following wrong advice.
-------------

"Breast cancer survivors have been getting bum advice. For decades, many doctors warned that lifting weights or even heavy groceries could cause painful arm swelling. New research shows that weight training actually helps prevent this problem.

"How many generations of women have been told to avoid lifting heavy objects?" Dr. Eric Winer, breast cancer chief at the Dana-Farber Cancer Center in Boston, lamented after seeing the surprising results of the new study. "Women who were doing the lifting actually had fewer arm problems because they had better muscle tone."

The study was led by Kathryn Schmitz, an exercise scientist at the University of Pennsylvania, and funded by the federal government. Results are in Thursday's New England Journal of Medicine.

More than 2.4 million Americans are breast cancer survivors, and the study could mean a big difference in their quality of life. Cancer treatment-related arm swelling now appears to be one of many ailments made better by exercise â not worse, Schmitz said.

"Fifty years ago we told people who had a heart attack not to exercise anymore," and people with sore backs to heal with bed rest, Schmitz said. "It was well-meaning advice but it was polar opposite of the truth."

The hospital generally doesn't make anywhere near that either.

This might be cynical of me, but my response is "just a politician being a politician".

@DoctorsWrongAgain @Happ*h:

Heya! Any Asians try to mind-control you recently?

Riddle me this: If I go to the hospital for an amputation of my foot and see a final bill, the total of which is in the range of $30k to $50k, would I care that it is the hospital that takes the vast percentage of that amputation, would I care that GPs and surgeons are paid separately, and would I even know any of that, even if I look at the invoice? Or would I say that the amputation cost me the amount I was charged, and then - like the common rube that I am - make the equivalence of "surgeon cut my foot off" and "it cost me $30k to $50k" to reach "the doctor charged me $30k to $50k to cut off my foot"?

Let's get back to how you guys make mistakes all the time instead of quibbling over doctor profit and hospital profit.

Hi, Happeh.

Bye, Happeh.

Again.

It's also, unfortunately, an understanding behind why a some patients seem to think that surgeons are making obscene amounts of money.

If it's not the surgeons, then who is, with that kind of bill?

My recent surgery cost somewhat north of $50K, and of what I make in a year. Of course I know the surgeon herself didn't make that much but for getting up in the middle of the night to operate for three hours and save my dumb ass I hope she walked away with more than dinner money.

Of course, if I didn't have good insurance, and a job with good sick leave, it wouldn't have mattered who was owed what, because I'd have been in real trouble twice - once from the medical problem and once from the bill.

Yeah, I wish Obama would be more careful, not give the teabaggers any more ammo.

I agree that it's a small thing in the bigger picture, but I can also understand Orac taking it personally as it's a reflection on his profession.

I live in Wisconsin and wasn't aware of Dr. Steve Kagan (I'm in Milwaukee and not a sports fan so don't take much notice of Green Bay). What an awesome thing! I'm going to write him right away and make a contribution even if he is rich. I have terrible allergies too, and no insurance, so maybe he'll let me make a good bargain with him for some allergy shots?

Seriously, people constantly ask why the people can't have as good a plan as the congress and this guy has stood up and taken the moral high ground--almost all others have completely ignored this very valid question. John Kerry was in favor of extending the coverage the congress receives to the uninsured and a few others have supported the IDEA, but Kagen has walked the walk and actually refused the insurance! I'm not a native of Wisconsin, but am very proud of my adopted state today.

And, from last month:

http://www.breitbart.tv/obama-doctors-taking-tonsils-out-for-money-inst…

Obama:

"Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. So if they're looking and you come in and you've got a bad sore throat or your child has a bad sore throat or has repeated sore throats, the doctor may look at the reimbursement system and say to himself, 'You know what? I make a lot more money if I take this kid's tonsils out.' Now, that may be the right thing to do, but I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change -- maybe they have allergies. Maybe they have something else that would make a difference."

There is a word for the kind of rhetoric that Obama is using with the amputation and tonsilectomy examples: conspiracy theory. This is a classic anti-allopathic/big pharma conspiracy theory: biomedical authorities could treat these diseases with less harm to and expense for the patient, but it's more lucrative to use invasive, destructive, or side effect-ridden treatments.

Yes, there is a legitimate argument about unnecessary tests and procedures, but the claim that doctors are deliberately allowing diabetes to progress to the point of amptutation simply because it's more lucrative is bizarre. And given that diabetes and foot amputation are more prevalent in the black community, that would be a collective civil rights violation on the order of the Tuskegee syphillis study. But it's just not the case.

I'm embarrassed for the president. And it's another unnecessary distraction from the healthcare debate the country should be having.

Aw I've missed Happeh, his crazy was always so much fun. He was like having a mad dog as a mascot...

Obama screwed up the argument, and not just because he quoted the global fee as the professional fee. The screwup is that in the case he quoted, the PCP gets the fee for cognitive services while the surgeon gets the fee for a procedure. So in this case, there's no conflict of interest.

The real problem is that physicians are heavily incentivized to act rather than to consult, examine, think, or counsel. The procedure fee is almost always vastly higher, per hour of physician time, than the cognitive service fee. That's true for surgery versus an office consultation, it's true for an echocardiogram over a detailed stethoscope exam, it's true for every instance of choice a physician has between spending time taking a detailed history versus ordering a procedure. This is a giant conflict of interest.

This is the dominant reason why medicine in the US involves more diagnostic tests and more procedures, at hugely higher expense, without measurably better outcomes, as compared to any other western affluent country.

My bias: I worked as a specialist in a "cognitive" medical specialty for many years, in an inner city hospital, before going to a research-only position.

Sure, Obama made a mistake here, but I think it was obvious what he was talking about: how much money is being spent, not how much particular people are being paid.

And I didn't get any implication whatsoever that he was talking about incentives for doctors.

The point was as clear as could be: Insurers (or medicare, etc.) pay only a pittance for prevention (of diabetes, in this example), but are willing to pony up $30k or more when lack of prevention causes the problem to get out of control (foot amputation in this example).

Do you really think he was making some other point? If not, the honest thing to do is say "Obama was obviously trying to say X, which is true and right, but in fact ended up saying Y, which is stoopid and wrong."

I guess it's a matter of listening/hearing differently - I heard him say that there's the high cost, and then that the surgeon gets reimbursed immediately. I guess it's the lack of visible punctuation in speech.

Not to feed the troll or anything, but I like to spell things out to people who don't understand.

DoctorsWrongAgain says don't pay attention to what scientists say. And to support that position DoctorsWrongAgain cites scientists.

We all rely on scientists to help us understand the world, even the one saying not to rely on them.

That surprises me. If someone is going to cut off any part of me, I want them compensated MORE that a thou!!
Thanks for this info. If I get an amputation, I'll be sure to tip the surgeon generously!!
JTD

Perhaps President Obama meant Zimbabwe dollars? :) 30,000 Zimbabwe dollars - now that's a cheap amputation! I can't even buy a chainsaw or bone saw for that price - hacksaw maybe, but who wants a hack job?

Hi, Orac. I don't want to feed the H-monster, but can you tell me, as a breast cancer surgeon, if the article he mentioned about no little/no exercise for BCS patients is correct? I can't access NEJM from work (tell me THAT makes sense, given where I work, but the firewall doesn't like the journal, at least today). However, seems to me that most BCS patients undergo physical therapy after surgery which entails lifting weights. Or am I wrong about this?

Let's get back to how you guys make mistakes all the time instead of quibbling over doctor profit and hospital profit.
The news story below talks about how doctors have been wrong about something for 50 years.

Just like they are wrong about masturbation making a person blind and crippled, the effectiveness of acupuncture, or human beings having energy.

Never trust a scientist. In 50 years someone will discover their "expert" knowledge was worthless. But only after making 50 years worth of patients suffer by following wrong advice.
===============
"Never trust a scientist" says the crank as he types away on his 3.2GHz, 2GB RAM, computing device. A device that only 30 years ago would have been the most powerful computing device on the planet.
More to your point - there are things that seem to make sense - people with heart problems shouldn't stress their hearts, people whose lymphatics have been dissected should not lift weights with that are- but turn out to be wrong once they are studied. Question: who eventually studied them and found out the truth?

I'm surprised at many of the responses here overlooking something that's not opinion but factually hideous and used to justify attacking one medical specialty, pitting it against another. A surgeon gets about $500 from medicare for a below knee amputation. That includes preoperative preparation, the procedure, about 3-6 visits in the hospital after the procedure and all office visits related to the procedure for 3 months after it. The dollar per hour reimbursement for that is not much more than what a primary care physician makes seeing patients in the office. Now take into account that the surgeon has a much tougher lifestyle than the primary care physician often getting out of the bed in the middle of the night to perform emergency surgery.
Overstating what a surgeon makes for a case by 30-50 times is egregious any way you look at it. Especially when it's to attack that physician for making too much and question his motivations. Politicians, insurance companies, hospitals....no one else involved in this debate has taken an oath to put the welfare of another party over all else the way physicians do with the hippocratic oath. The decision to amputate someone's leg is not taken lightly and is not motivated by anything other than what is best for the patient. Stating otherwise is disrespectful to the physicians of this nation and undeserved.

The responses that excuse the $30-40k mistake do not make sense. Obama is using that figure to make a point and when that figure is way off it undercuts his argument. He's using that large figure to imply that the amount of money is motivating decisions and directing care provided by physicians. Excusing it by saying he's confused regarding the global fee for all the care ignores how he was trying to use this disinformation and his lack of knowledge of the healthcare system.

The whole point of his argument was to make a comparison between prevention vs. "sick-care," or critical care. It is TRUE that the total cost paid out by either a government program or insurance company would be much less for prevention than it would be for amputation surgery. If you look at the total cost, he's right that disabetes amputations cost roughly 30-60k (that's the COST to society). He's not trying to imply that doctors would willingly wait until a patient gets sicker and sicker so they can give them an aputation. He's merely saying that most people don't go to the doctor on a regular basis because it costs money (i.e. there is a problem with prevention in this country). If going to the doctor didn't cost people anything (or very little - like $10), then people would go more often and prevention would be more common. In the long term, the total cost to society would be less because prevention is cheaper than caring for people when they reach a critical level.

People are confusing two different points in the health care debate that Obama has actually been relatively careful to keep separate:

- Payors (private insurance, Medicare and Medicaid, etc.) have been penny-wise and pound-foolish in setting up a system where they must pay for acute, undeniable problems (a limb requiring amputation) but do not pay for the non-acute preventive measures that could have kept the acute problem from happening in the first place (patient education and monitoring to keep diabetes in check).

- Doctors are incentivized by these payment systems to give more or slightly different care than they would if the payment system were built differently. Another test or two "to be sure," a slightly more expensive test, or even removal of tonsils as a preventive measure (which was fairly popular back when dinosaurs roamed the Earth and I was a child) might result. Doctors of course recognize the problem of perverse incentives themselves, and many have taken measures to try to preserve a more complete objectivity of medical judgment in particular areas - for example, banning office visits from drug company reps to remove the incentive to prescribe a brand vs. generic, or one drug vs. another.

A payment system change currently being touted as a remedy is "capitation," paying a flat amount per patient per month so the physician's incentive is to be what some would call "cost-effective" with treatment. One huge problem with this is that it could tend to incentivize inadequate care. This is what led to the more egregious past abuses of the HMOs - docs were not only capitated, those who performed higher volumes of procedures anyway were dropped from HMO networks, resulting in cost-cutting companies with networks of the most aggressive cost-cutting docs, and patients who arguably didn't get all the care they needed. (See also the original "penny-wise, pound-foolish" problem discussed above.)

So fee-for-service tends to incentivize more care than is needed, capitation tends to incentivize less than is needed, and achieving a balance is very, very difficult.

Yes, I know what Obama was trying to say. My point is that he botched his point badly enough to warrant an EPIC FAIL in that he did more than infer that the reason modern medicine opts for an amputation over diet, tight glucose control, close diabetic foot monitoring, etc. is because of the financial considerations of the doctor. If he had said it was a systemic issue in that it was wasteful not to invest more up front in measures to prevent amputation in order save money later, I'd have had no problem with it. But that's not what he did. He stated that physicians make hundreds of times more money than they do for a procedure and used that error to strongly imply that financial considerations are what drive the decision for amputation, all the while forgetting that it's not even the same doctors we're talking about. Primary care physicians don't do amputations; they don't get more money if their patient has to be referred to a surgeon for amputation.

No, Obama screwed up. I know what his message was intended to be. He just botched it royally, demonizing surgeons in the process.

Too much rhetoric and little action, this must be corrected immediately, I hope that obama will change the perspective and ortiente better.

The incentives in our current health care system are badly misaligned. There's this article in The Atlantic http://www.theatlantic.com/doc/200909/health-care/ and on page 4 you have this excerpt:

indeed, because my dad got sepsis in the hospital, and had to spend weeks there before his death, the hospital was able to charge a lot more for his care than if it had successfully treated his pneumonia and sent him home in days.

He's clear that he doesn't think the hospital purposely gave his dad a life-ending infection. But hospitals that control infection aren't financially rewarded -- if anything, they get slightly penalized.

It is not a simple, harmless mistake. When making health policy decisions, a mistake like this can be epic. If we confuse doctor's fees for the entire cost of something, and then cut doctors fees, we've reduced the total cost by a small percentage, and harmed the clinician at the same time.

It is an epic fail.

It just seems a small thing compared to the damage the lunatic fringe is doing with their town hall disruptions and "death panel" lies. A lot of this type of argument seems to show that single payer would be best as it would leave medicine to docs and others on the front lines and eliminate the misspeaks of politicians who may mean well, but cannot be as well-informed as those directly involved with health care delivery.

One other note: The term "prevention" needs to be defined. The CAM crowd certainly means something different when they use it than a doctor or nurse practitioner would mean. Kind of like "affordable" means something way different to a single mother working two jobs than to a real estate developer.

An incident my sister told me about at her family clinic:

Kid at her practice needed supportive/corrective leg braces. HMO will not pay for leg braces; not "necessary". Alternative to leg braces is a series of surgeries when kid hits adolescence, which would cost 6-10x as much as the leg braces. HMO will pay for that, because surgery by late adolescence would be necessary.

It really isn't a system that makes sense. Shame that Obama had to muck up the argument so badly.

A layperson doesn't give a damn about who specifically gets how much money out of the fee - if the bill says 30-50K, that's the price as far as they are concerned, whether the doctor gets half or 1% is beside the point to us.

So your claim that Obama made a mistake about the price may be correct as far as how a doctor would understand his statements, but it's wrong as far as anyone else is concerned.

Now the other argument Orac made in the comments, not the OP - that this is a bad example of how financial incentives can skew healthcare - that certainly seems like a good argument to me. And Obama should have used another example.

Orac - Obama makes a gaffe and says doctors charge $30-50K for an operation. You latch on to that gaffe and call it an "EPIC FAIL". I disagree: it is a fail, but not an EPIC FAIL. An EPIC FAIL would imply that the majority of the things he said throughout his town hall were ignorant or blatantly false, which they weren't.

On this particular issue - one of MANY brought up at that town hall - did he make an EPIC FAIL? Umm.... like John (@12) Coriolis (@38) indicate: to the majority of Americans (i.e., the majority of Americans aren't in a health care related job) will see a bill for $30-50k following their operation and equate that with a "doctor's bill". If you are going to argue for anything, you should argue either for mandatory education about medical expenses or argue for mandatory itemization of all expenses on all billing to all Americans. (You could also argue for greater linguistic clarity on everything that anyone says or writes, but that would end up being a futile exercise.)

I hate to say it, but your moral outrage here seems to stem from a desire to protect what you see as an attack against your profession (which I think is misplaced) instead of putting it into a POV that accepts that most people don't know the first thing about how costs are tabulated, and who gets paid what amount of money.

Kid at her practice needed supportive/corrective leg braces. HMO will not pay for leg braces; not "necessary". Alternative to leg braces is a series of surgeries when kid hits adolescence, which would cost 6-10x as much as the leg braces. HMO will pay for that, because surgery by late adolescence would be necessary.

This is actually logical from the HMO's point of view. What are the odds that the kid's parents will still be working at the same jobs when it comes time for the surgery? And therefore, what are the odds that they'll still have the same HMO?

So by putting it off, while the ultimate cost is much greater, it's likely that some OTHER insurer will end up having to pay for the surgery, so it saves the current HMO money.

I work in Medicaid claims as a data analyst. We just recently did a data mine for our state following diabetics that required amputations for 4 years, 2003-2006. We followed approximately 50 patients, and just looking at their costs incurred for amputations the average spent was $46,000. The minimum spent was ~1200, while the maximum spent was ~255. The biggest problem we see arise with diabetic amputations is that once you start cutting, you keep cutting. The really out of control cases are where the majority of the money goes.

Now I don't agree that the doctors are choosing to amputate for more money, I don't think this is the case. I do not have a problem with the figure quoted pertaining to diabetic amputations though.

To avoid confusion: The maximum was $255,000.

I had cataract surgery a couple of years ago. Total bill for one procedure -- what my insurance paid -- was over eight grand, of which my surgeon, arguably the best in the area, got about $750. I was embarrassed when I read the bill.

$1,000.00 for the amputation and follow up care?

While such surgical procedures are not as dangerous and potentially life threatening as they had been years ago, given the responsibility and accountability involved, I think that the surgeon fee is quite reasonable. I work in accounting for a publically traded company and you would just not believe what we spend for legal and CPA services. Auditing fees in particular are outrageous. Also, unlike medical facilities, law and accounting firms don't have much overhead.

I'm not sure if the following is representative of the general situation. Comments are welcome.

For several years I was a financial aid advisor (federal Pell grants, Stafford loans, work study program, and NY Tuition Assitance Program grants) at a 2 year private college in Buffalo, NY. My PCP (he did minor surgery but nothing big) had a daughter in grad school and he asked me to analyze his federal and state applications before he sent them in. As it worked out he was in an income bracket where the eligibility was only for loans. His 1998 income (from being on-staff at a very large hospital and running a healthy practice :-) wasn't much more than $100,000.00 (I saw his tax returns). Yes, that's a very good amount of money. But considering what he does and that the general assumption is that doctors make a lot money I was surprised by the income figure. Therefoere, I wonder if perhaps "front line" PCP/family practice type doctors don't generally make as much as people assume.

One problem with Obama's two comments, first about tonsillectomies, then about amputations, is that there are two of them; he didn't learn from his first error.

The other problem is that both comments appear to feed another hysterical group, the group that seems to think that doctors make ungodly amounts of money, never mind the personal and financial costs of the years of education, commitment to the medical profession, and the truly ungodly cost of malpractice insurance.

Personal question on this topic:

A non-insured person had a deep cut in a finger and required nerve reattachment and plastic work. The surgeon - and only the surgeon - billed $17,000. (Total bill was around $30,000) Is that insane? Where can you research costs of typical surgeries?

Much thanks to whomever answers this.

President Obama's point was that insurance companies will pay $30-50K for a diabetic's amputation but will not pay nearly as much for a doctor whose treatment prevents such an amputation. Reading through the comments, no one is disputing that the total cost is $30,000-$50,000. No one is disputing that Obama's underlying point about mismatched incentives is correct. Instead, everyone is quibbling about the distinction between the doctor's share and the hospital's share. Yes, facts matter. But Obama misspoke. He was not lying or completely making stuff up.

And we wonder about the low quality about the national debate.

My, William, you sure do like the straw men argument. No one said that Obama was lying or making things up. What we are saying is that he needs to be a lot more careful with his facts, which he failed to do. In essence, he made it sound as though doctors had some sort of incentive to let diabetic feet proceed to amputation and that surgeons are getting rich on this stuff.

Of course, one can't help but note that your straw man argument is good evidence of the very thing you decry: the low quality about the national debate.

In the first post, where mdielhl refers you to a web site that praises Dr. Kagen (Dem WI), no one mentioned that Dr. Kagen got into trouble with the FDA over the sale of his medicine. Nor was it mentioned that Dr. Kagen's clinics would not accept medicare payments. Nor was it mentioned that Kagen lied about cornering Dick Channey in the capital and reading Channey the riot act. The list goes on.

The 45th comment is right, you guys have no idea on the commitment it takes to go into the health care profession, and the valuable years it takes to become a successful surgeon. Look at your stupid sport athletes, they're making almost 6 times more than the average doctor. How come we can't cut their spending and provide it to the health care. I mean it would help a lot, but these surgeons get their pay check deducted from taxes and etc... The years of hard work, should give the right to earn a nice amount of money. Our soldiers should also get paid a lot of money, for those fighting in Afghanistan.

Doctors are paid far too much, I drive past a Hospital every day on the way to work, and I see the kind of high end cars doctors drive. They have plenty of money.

The incentives need to change, as Obama pointed out. Not only on this, but also tonsil removal, where doctors are removing tonsils simply because someone is suffering from allergies. I'd like to see Medicare for all, with all medical procedures reimbursed at Medicare rates. Then the medical profession would attract people interested in helping, instead of people interested in making money.

Holy threadomancy, Batman!