Or maybe not? Should doctors be salaried workers? From Political Animal:
UNKIND CUTS?....Last month Blue Cross put physician reimbursement cuts into effect in California and doctors were predictably outraged. "I don't know how anybody can afford to stay in practice and accept Blue Cross rates," Dr. Charles Fishman, a San Luis Obispo dermatologist told the Los Angeles Times. "Boo hoo" was undoubtedly the response from many readers. It's hard for the average American to feel much sympathy for a profession where the median income is $215,000 a year. Soon, Medicare will be making its own cuts, and we'll hear a new round of complaints from doctors.The point of all this cutting, of course, is to rein in spiraling health care costs. But reducing reimbursements to doctors never works in the long run, and you'd think payers would have learned that lesson by now. Why doesn't it work? Because medicine, as Dr. Arnold Relman, the former editor of the New England Journal of Medicine, once observed, is the ultimate piece work industry. When you pay them less per "piece," physicians can and do increase the volume of services they provide in order to make up for lost income.
That means that we don't end up saving any money by tightening reimbursements. But we do end up pissing off doctors, who don't really want to have to run around doing more procedures and seeing more patients just to maintain the same income. It also means we patients can expect to be given a lot more unnecessary procedures, because when doctors do more, they don't necessarily do more of what we really need. In the 1990s, managed care trimmed physician reimbursements and an avalanche of unnecessary procedures and blood tests and CT scans was the result.
All of which is just one more reason why fee-for-service has got to go. It's a broken payment system, and it simply encourages bad quality care. Doctors need to be put on salaries.
Alan Sager, at Boston University, suggests that we take the portion of our national health care bill that already goes toward physician reimbursement -- about $500 billion -- and say to doctors, in effect, you can keep the money, but you have to take it in the form of a salary. Surgeons would no longer be paid separately for each surgery, and primary care physicians would no longer get a separate fee for each office visit.
We might want to redistribute the money a bit, so primary care doctors make a little more and the super-specialists make a little less. The main idea here is to recognize the fact that we can't save money by squeezing doctors, and what we ought to be doing is removing the financial incentives for giving patients care they don't need
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I'm staying out of this one. Discuss.
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Someone did a survery a few years ago about public perceptions of doctor's salaries. The found that:
1) Most people thought doctors were paid too much
2) Most people thought the median income for physicians was around $100K, not $200K
Perhaps we should be looking at the salaries of health industry executives. Could we get rid of waste by lowering the compensation of HMO executives? I want my doctor to be happy and compensated well. How can people think $100k per year is too much for a doctor, who actually improves quality of life through specialized knowledge and training, whereas "professional" athletes get paid millions of dollars for merely playing a game?
It seems like a case of misplaced priorities. People spend money on NASCAR merchandize and sporting event tickets, but balk at the thought of paying someone who can cure disease.
The orthopedic surgeon who repaired my rotator cuff told my relatives, who he happened to see for another reason, that his office had scheduled him to see 80 patients one day. I had to change dentists because my regular dentist couldn't fit me in for an emergency filling replacement - no openings for weeks. I had to go to a doc-in-a-box because my regular physician couldn't see me for two weeks about excruciating hip pain. Do doctors overschedule because of low payments or because of greed? I don't know.
Reasonable salaries for doctors (even as much as the median today) sounds like a fine start, but removing health care payments from for-profit insurance companies is an important part of the solution, too. It's obvious that the present sytem doesn't work.
Good grief, will the socialists ever find the inner strength and personal discipline to shut up already with these 'utopian' solutions? Sometimes I wonder what they think at night when their little heads are resting on the pillow - "If only we could get people to work for less money, then we'd have more money to spend on people that I deem worthy of receiving alms."
Here is the comment from Sharon Brownlee, the author of this above excerpt, posted on the Washington Monthly website on 9/3:
First, let's remember that there are lots of doctors on salary -- at places like the Mayo Clinic, and Kaiser Permanente, and Group Health Cooperative of Puget Sound, the Veterans Health Administration, and Intermountain Healthcare, some of the best organized medical practices around. The key word here is organized, but I'll leave that part for another post. These systems are either prepaid, integrated Health Maintenance Organizations (to be distinguished from the managed care we all learned to hate in the '90s). Or, in the case of Intermountain Healthcare, an integrated hospital system that hires its physicians. Or a government-run system with a budget, a la the VA. They are also demonstrably better at delivering high quality care than the rest of the fee for service world. So who would salaried doctors work for? Either an HMO, as is the case in Group Health and Kaiser; the government, as in the case of the VHA; or a hospital system, as in Intermountain Healthcare.
Yeah, yeah, yeah, I know, everybody is blowing a gasket right now, saying I'm crazy if I think Americans are going to go for either a government-based system like the VA, or an HMO. All I can say is, look at the data. These systems all do a better job of delivering care that people need, not giving them stuff they don't need, and doing it all for less money. Oh, and the doctors who work in them are generally more satisfied with their jobs. Who would pay? Well, employers and individuals pay HMOs directly. All of us who pay taxes help support the VA system. I don't know how Intermountain gets paid.
Posted by: Shannon Brownlee on September 3, 2007 at 4:21 PM
I'm having trouble controlling my laughter as I read her solutions to this horrific crisis. Does she really think that doctors will get down on bended knee in Paducah, Kentucky, or Crosby, Minnesota to thank our government for giving them the opportunity to practice like the libs in Puget Sound, or worse, a VA hospital?
Whenever a "progressive" suggests that some professions ought to not pay their workers for the work they do, or should pay their workers the same amount whether they produce anything or not, you should grab your wallet and run quickly to buy Thomas Sowell's great book The Vision of the Annointed.
I think Ayn Rand's comment from Capitalism: The Unknown Ideal says it best:
"Economic power is exercised by means of a positive, by offering men a reward, an incentive, a payment, a value; political power is exercised by means of a negative, by the threat of punishment, injury, imprisonment, destruction. The businessman's tool is values; the bureaucrat's tool is fear."
Hmmmm... It seems to me that if we take the net cash we're spending on health care and enumerate what we're spending it on, physician reimbursement is probably one of the more justifiable expenses. Remember, most of the money goes somewhere else. In theory, you should be paying for the physician's time, the time of the associated support staff, and whatever materials / infrastructure is needed. I seriously doubt that it's that lean in reality, and I bet that we can cut out other fat before dinging the people who actually provide the service.
What I find more irritating about the medical industry is that for all the appeals to the free market, it behaves like no healthy market I've ever seen. Raise your hand if you go in for a consultation or treatment and only learned of the cost after the fact when you got the bill? Better yet, did you ever know what the real cost was? Did you get any sort of a competitive bid? Any idea what market price was? It's hard to make a market like medicine work like a healthy free market, and I really don't see "inflated" salaries for doctors as the primary issue.
Well, cheerful, I kept waiting for some kind of solution. When you quoted Ayn Rand I knew nothing would be forthcoming.
Well, cheerful, I kept waiting for some kind of solution. When you quoted Ayn Rand I knew nothing would be forthcoming.
Mark P, my comment wasn't a solution, it was what I believe bloggers call a 'rant.' Here is my solution to the problem of third party payers cutting reimbursement to physicians for the work they do:
In terms of the choices that are in front of us politically in today's environment, we are either going to have a government-run health care system or we are going to have a private, vigorous, healthy, consumer-oriented system where we actually allow market forces to allocate these scarce resources. We cannot afford what we are doing today.
On the one hand, if we have a government-run system, we might control the costs, but we will do that at great price. The way costs are restrained in every other government-controlled system is through rationing. What that means is that healthy people die earlier, people with disease do not get treatment on time, and the long-term consequence to a mobile and healthy society is that you lose productivity as people age.
All you have to do is look at the statistics, whether it is Britain or Canada or any other government-run system. For example, cancer patients in England have to wait too long for chemotherapy. Think about what happens during that time: the potential benefit for a cure, the possibility for a cure.
So we have to make a decision in our country: Are we going to have the government making the choices that are rightly yours to make? Are we going to have the government running health care? Are we going to lose the innovation from a health care system that has produced 75 percent of the advances in health care that we have seen over the past 30 years, or are we going to go to something that we have proven in our society will allocate scarce resources, create great opportunity, advance quality, and give better price and better transparency?
My belief is that if the American people are given a choice, they will choose a market-oriented program. It fits with our culture, and it fits with our society. It's based on freedom; it's based on choice; it's based on decision-making; and it's based on accepting the consequences for the decisions you make.
The above was written by Senator Tom Coburn, M.D. The entire article, entitled "Competition: A Prescription for Health Care Transformation" can be found at this link:
http://www.heritage.org/Research/HealthCare/hl1030.cfm
Attention members of the mainstream media: for interview requests please contact the staff of my air-conditioned 40 foot luxury yacht. Her name, by the way, is self-explanatory.
Can I just hit myself in the head with a large rock instead? it would be cheaper, and it sounds like it would have the same effect.
But, oh no! I wouldn't be doing my part for the economy! The book stores would all shut down! Woe, woe, woe!
Can I just hit myself in the head with a large rock instead? it would be cheaper, and it sounds like it would have the same effect.
But, oh no! I wouldn't be doing my part for the economy! The book stores would all shut down! Woe, woe, woe!
OJ, CO, that is a suggestion at least. In my opinion, it is the wrong suggestion. The obvious solution is for the government to run the health care system because we already have a competitive, market-driven, private enterprise health care system and it does not work. The idea that competition can work in health care is absurd. I have heard consumer advocates talking about buying health care (not insurance, but health care itself) in the same way you buy a car. I can just see it. I tore my rotator cuff, so I should have solicited bids from the orthopedic surgeons in my home town, then from the anesthesiolgists, then from the hospitals, then from the nursing staff, compared them and bought accordingly. The whole idea is so stupid it beggars the imagination.
Uh, do most people realize that 97% doctors straight out of residency are in debt, many of them in the $100K+ range? (I personally will owe over $200,000 by the time it's all over.) And do they realize that doctors pay anywhere between $6,000 and $250,000 a year in malpractice insurance, depending on their professions and their geographies? And do they understand that if you're in primary care, you get reimbursed a teensy weensy amount for each patient you see, and even less for patients on public-assistance insurance? And that we also have to pay taxes?
Doctors are a heterogeneous group, sure. And many doctors make pretty good money. Those tend to be specialists in procedure-heavy fields. Primary care docs, especially early in their careers, are not making big bucks. And now they'll make even less.
Don't even get me started on the unbelievable amount of bullshit you have to put up with for the pleasure of serving the sick public, y'all. One 30-minute visit with a borderline, drug-seeking, irritable-bowel-syndrome-having patient, and you'd be begging to pay us more. BEGGING.
I'm just saying.
Are we going to have the government making the choices that are rightly yours to make?
Why do people think I want to or have to time "shop around" for health care? What a pain in the ass. I'd much rather just go in, get someone competent, deal with the problem, and leave. I'm not sitting around in the evening twiddling my thumbs and thinking, "if only I could be researching what doctor I want to go to".
cancer patients in England have to wait too long for chemotherapy.
Millions of people in our country can't get health care AT ALL. That is simply MUCH WORSE. Not to mention that, being that we already spend several more times over per person on health care, one would think we could leverage those extra funds into cutting wait times.
Are we going to have the government running health care?
I like how this statement is supposed to make us cower in fear. That's not an argument. I could just as easily ask "are we going to let money-grubbing corporate suits who don't have our health in their best interest run health care?" Oh wait, we already do.
Here's my problem with the rah, rah capitalism argument. When you look at the motivations, things don't add up. Health care companies want to make money. When Apple (for example) wants to make money, they invent iPods, we buy them, everyone's happy. When a health care company wants to make money, they are motivated to engage in practices that do not improve peoples' care. The government, (which, I should apparently remind people, isn't some evil faceless entity but in a democracy is US), has peoples' health in its interest.
Actually, being an academic physician, I already work for a salary. I could make more in private practice, but the differential is decreasing.
As for this "solution," it neglects a number of things, not the least of which are for-profit health insurance companies. I'm also very skeptical of the claim that there was an "an avalanche of unnecessary procedures and blood tests and CT scans" due to reimbursement cutbacks in the 1990s. For one thing, ordering blood tests and CT scans do not add to a physician's income. Even if I were in private practice, ordering such tests would not make me a red cent, although it would make money for the lab and for the radiologists who do the tests. A small proportion of such tests might uncover abnormalities that need treatment, but that's a really long run for a short slide, given the low yield. I'd have to look at lots and lots of tests to find one patient who needs a procedure.
In other words, although the idea of salaried physicians has some merit, this Brownlee character is full of dubious assumptions on a number of levels.
As for the concept of a salaried physician, which, being one myself, I don't have an intrinsic dislike of, even Brownlee's solution leaves out the fact that a significant fraction of reimbursement does not come from Medicare and Medicaid, but from private insurers. The government could try to become the employer of all physicians by paying physicians on salary, but that leaves out a huge area of reimbursement. And if this proposal involves taking that private insurance and including it in the pot that provides physician salaries, then that is a de facto nationalization of the health care system.
It would also be a bureaucratic nightmare not necessarily any better than the present system. As a commenter named jon said:
Doctors presently get money from government healthcare, corporate healthcare, and private payers (and combinations of all three.) How would they merge?
Would a doctor that sees 90% private persons paying cash and 10% Medicare/Medicaid get 10% of the government maximum salary? What about a guy who sees 10% private, 30% private/corporate, 30% government healthcare and 30% government/private patients but only fully treats the private patrons? I see the doctors not having to let any of their office staff go. Right now, handling the billing is more than a full-time job or two for most doctors' offices. How this can be fixed will have to be part of the solution rather than an addition to the problem if this proposal is to have any chance of flying.
All in all, although having salaried physicians is not intrinsically a bad idea, Brownlees proposal is a pretty dumb way to go about it.
Signout, your comment is actually an execllent argument for universal health care run by the government, from start to finish. A properly-designed system would eliminate all your complaints, which are the result, you should know, of the way the current system works.
The government has people's health in its interest?
What planet are you from?
We don't have our own health in our interest?
When a health care company wants to make money, they are motivated to engage in practices that do not improve peoples' care. The government, (which, I should apparently remind people, isn't some evil faceless entity but in a democracy is US), has peoples' health in its interest.
The first sentence of this comment is ludicrous and belies any knowledge of how health insurance companies make money.
The perspicacious reader might have trouble interpreting the following 'practices,' taken directly from the United HealthCare web site, as evidence of a malevolent desire to debilitate their customers' health:
The latter sentence of this comment, if posted in the doctors' lounge of any hospital, would serve as an incalculable source of hilarity for our men and women in the trenches of 21st century medicine. Jack Benny would have killed to have such talented writers.
Supporters of the current system are making strawman arguments. No one says that insurance companies want their customers' health to be bad. What the insurance companies do want is to make a profit, and they do whatever they can to that end. If it means giving free advice to try to avoid having claims, they do that. If it means denying claims or dragging their feet endlessly on claims, they do that. As I point out to my wife when we deal with our insurance, the insurance companies do not pay their claims adjusters to pay money for claims, they pay them to help the company make money. They do that by denying claims, not paying them. Let me remind you, insurance companies are in business to make money, not pay claims.
Let me ask a question. Who, other than a person who benefits from the current system, would defend the current system?
Interesting that you should equate "we" with the federal government.
"We" generally do have our own health as a major interest. It does not follow from that that the federal government necessarily does.
Mark P, thanks, better than I could have said it.
Orac, if "we" and the federal government can't be equated, then there are major problems and we should consider revolting. What interests would the federal government have other than a concern for the health of the citizens? There's no money to be made, and we system would be, if excuted properly, transparent and under the peoples' own supervision. Nobody's calling it easy or trivial, but there at least are not ulterior motives.
Actually, in this country, the federal government is we. Read The Constitution.
Doctors comprise 20% the cost of health care in the US, insurance company overhead runs about 30%. If we went single payer, we could cut that to 5%, freeing up enough money to pay for twice as many doctors and still cut 5% of our health care spending. We can do without insurance company overhead a lot better than we can do without doctors.
GPs have a median income of about $160,000 and the typical GP has to pay for malpractice insurance and continuing education out of that. It's a good return on five or six years of post graduate education but not an astounding one.
That income of $80 an hour requires a loaded cash flow on the order of $320 to provide medical services. Clinics have a lot of overhead. If a visit can be billed at $40, expect 7 minute visits, less time out for paperwork.
$160,000 sounds like a LOT of money, but it is nothing compared to the millions in salary paid to insurance company executives, and even less than the billions of dollars that they waste. Of course, it isn't fashionable to envy our betters. The only fashionable envy is of those with a little more.
thank you very much