For those new to me and my ramblings, I am a primary care doctor in a sliding scale community clinic situated in a medium sized community hospital. I have worked a number of practice settings, including the large teaching hospital where I trained, a small rural hospital owned practice, a small physician owned private group, and now a large community medicine organization.
In the endless parade of political angst circulating on Facebook, today we see This Article and This Rebuttal.
The first article basically says that workers in the medical field are all overpaid. While presenting inaccurate statistics and naive claims about the market, the author does make one crucial point. Doctors have been off limits when responsibility is assigned in our horrendous excuse for a health system. The article is eliciting a number of angry responses with the second doctor's being one of the higher profile. The original article's ignorance about the economics of the medical field make it easy pickings.
But that one point lingers. What is the role of the doctor in the health care debate?
Doctors exert power through the orders they write. When we choose one medication over another, prefer a specific type of testing, or direct where a procedure is done, we control the flow of enormous sums of money. Certain orders have more consequence than others. Some realms (radiologic testing and surgeries being a typical example) are known profit centers. Others (such as ICU stays) are known loss centers. The amount of money flow a doctor controls is easily 5-10 times his or her salary. Systems with interests both at the office and hospital level will take losses on salary to retain a physician whose orders then net a profit in orders. This is a key point, one that makes much of the first article irrelevant. i.e. Salaries aren't the issue. Patterns of orders, and the resulting flows of money, are the issue.
There are numerous laws trying to prevent conflicts of interest and outside influence on a doctor's medical decision making. The blatant trips and bribes of the past have been drastically reduced, and there are restrictions of self-referral. However, the basic fashion in which the majority of physicians are paid inherently drives up cost. Most physicians are compensated with a formula involving some base pay and a production factor. The specifics and ratios vary widely, but the production aspect is central. For a self-employed physician, there is no base. This would seem to make sense from a market perspective. However, production is almost always measured in number of patients seen or procedures performed. The more people I see (the less time I give each one) the more I get paid.
The implications range from obvious to scary. Obvious is the much lamented 3 minute visit where the doctor doesn't seem to listen. Troubling is intentionally having patients return more frequently just to boost revenue. When we up the ante to surgical procedures, we get assembly line surgeries and at worst performing unnecessary surgery and overestimating illness as an excuse.
The part that most outsiders don't know about is how much power these choices create, not in terms of personal salary, but in influence in the medical system. A doctor (or group) that does a high volume of surgery can make or break hospitals by choosing one site over a rival. Rules are often bent for revenue producers, abuses ignored. Those that might be in a position to curb behavior as it heads into unethical territory have a vested interested in taking no action. Colleagues are loathe to take action lest their own practices be scrutinized.
The only real control on this is a patient walking out the door and choosing a different doctor. Unfortunately, this process involves numerous barriers and will actually be the subject of an entire future blog entry. Suffice it to say, that the patient doesn't have enough knowledge or choice to exert meaningful market forces. Quality controls and measures are increasingly being attempted, but for the most part these are bureaucratic wastes of time and do not capture the behaviors that are truly draining our system.
The incidence of criminal fraud to increase services and revenue is low but not zero. However, many doctors hover the line of ethics and it is very profitable to do so. While the author of the first article complained about salaries of primary care physicians at $200k and specialists at $350k, a doctor who pushes the system to the limit can make in excess $350k as a primary care doctor and well above $500k as a specialist. Sadly, my experience is that some of the assembly line docs actually are some of our brightest colleagues when a difficult case arises. Most have brilliant rationalizations for their practice patterns. Few admit to themselves, let alone out loud, that they are pushing the line.
Many topics in the health care debate have been untouchable, and I've only brought up a few here. To be clear, I do not think doctors are the root problem. But they are part of the system that IS the root problem. Some doctors are actively trying to change this system and try desperately to avoid the pitfalls I've described. But even those activitist docs are stuck in the systemic bind our profit-based system creates. Whether doctors created or are victims of the system doesn't matter now. The doctor and his or her choices are a significant sustaining force for this dysfunctional system, and cannot be ignored if we are to create something better.
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