Do physicians have an unusually high sense of financial entitlement?

Great Debates
1

So I was reading this article on CNN about this doc who is “fed-up” by not reaping the benefits of the “savings” he generates for the insurance companies and Medicare. Some tidbits for you.

and

Now, I don’t know how it is where you work, but since when does NOT ordering something that is NOT needed mean you “saved money” for someone? If you are not ordering procedures/labs etc… that are NOT needed then you are DOING YOUR JOB. If you ARE ordering these things when you know they aren’t needed then you are NOT doing your job. It’s a simple as that.

I work in DoD acquisition (save your jokes). Should my pay/performance be based on what I DIDN’T buy? Yeah, responsible acquisition is knowing when to walk away, but I don’t get accolades for not buying and Air Warning Radar when I know it’s going to be used in a region without an air threat or without an air force to speak of. If I bought that radar it would be fraudulent, as would ordering labs you know aren’t needed.

You aren’t special doc. Millions of people decide what NOT to do/buy every day and “save” MILLIONS of dollars in the process and don’t see a dime of that savings. They just get their regular paycheck, which brings me to my next point.

and

and

finally

That last quote is dubious… but the point of the previous 3 is this. So he is only getting $75/55 per patient is what he’s telling me. If this guy spends, what I’m guessing is an avg of 10 minutes at most with each patient, he probably sees 30-50 patients a day right (this number could be WAY off I admit)? At the low end that’s $1650/day. At the high end thats $3750/day. That’s $429k low/$975k high per YEAR in income. That’s ALOT of $$$

I know this is rough math not supported by anything but my calculator and a couple WAGs but it goes to show that, for some reason, many doc’s feel entitled to compensation that is not normal or expected in other fields. Yeah med school costs alot but so did my BS and MS EE (probably spent $100k between the two).

Where does this come from? I hear frequently that doc’s feel underpaid. If anything they are over paid at worst, properly compensated at best. I don’t see the short sell doc’s seem to think they get.

So my debate is:

Are doc’s underpaid?

Should they receive compensation for “saving” money in the ways described in this article? (NOT buying unnecessary things)

Does this have anything to do with the astronomical cost of healthcare?

Should I receive a bonus for NOT purchasing things I know are not needed?

Should you?

(Before it happens I realize not every doc is like the author of the article and I used a fairly broad brush for the sake of the debate)

2

I think his concern is less that he’s not making enough money, but that the insurance companies are making too much money because of his work. If a doctor orders an expensive test to rule out something, he gets some quick bucks. If he takes the time to rule that something out using other methods, he gets nothing, while the insurance company saved a bundle on tests.

Although, I’ve always heard that insurance companies give bonuses to doctors who stay below a certain threshold of expense per year.

Personally, I think a for-profit company telling a doctor how to do his job, and rewarding him for doing it “efficiently” is kind of crazy backwards.

Doctors are put in a tricky place, financially. It costs hundreds of thousands of dollars to become one, and the cliche is that all doctors are rich, but it takes a long time (and sometimes selling out) to get there.

My doctor is from Iraq, and he says he makes a comfortable living for the amount of work he does and doesn’t think he should sacrifice patient care in the interest of making a giant insurance company happy and the hope of a few more bucks. Good guy.

3

I think that what this doctor is trying to convey is that the current system of reimbursement rewards the wrong things, and that in some cases this reduces his income. I believe that I heard a doctor on NPR state that she is reimbursed at a higher rate for interpreting an MRI than she is for diagnosing the same ailment correctly without an MRI. She also said that she was paid more for one little ingrown toenail procedure that took 15 minutes than she was for all of the other patient consultations she did in the same day.

I didn’t get a greed vibe from the quotes in the OP, just a sense that the doc feels that the system messed up in terms of incentives.

4

I don’t tread in GD much as is probably evident by my OP. I don’t specifically mean that they are being “Greedy” more that they believe they are worth more than they are. Does that make sense? Not so good at this. I see greed as being a money grab. Get as much for as little as you can.

The doc in the article clearly sees NOT ordering a lab/test that he KNOWS is unnecessary is SAVING money, either for himself, the insurance company or the patient. That’s just not the case no matter how you look at it. It may be “saving money” compared to a different, inept, physician, but it’s not saving money to do your job. It just isn’t.

And I call BS on the “$100’s of K for med school”. Yes there are elite med schools out there that cost that much, but I’ll bet that the majority of your run-of-the-mill docs paid less than $150k and that includes room and board. If you include room and board in my BS/MSEE then I’m probably close to $150-200k myself.

I think and individual working 40-60hrs/wk and taking home over $500k a year is very well paid not matter what they do. Ditch digger or doctor that’s a well paying job.

5

I think this is a monster created by private healthcare, and a good example of why I am happy we still have socialised care here.

Some things just aren’t suited for the private sector due to poor incitament structure. Energy, Police, Military and Healthcare are some examples.

6

That’s a lot of assumptions. I suspect that your “number of patients” is way inflated. It may also be that the $75 per patient is not his take-home salary, but the amount he charges, out of which he has to pay all sorts of expenses. I think you’d be better off looking up the actual yearly pay of a doctor like this.

I don’t know exactly how much doctors are “entitled” to make, but it makes perfect sense to me that they be one of the highest-paid professions out there:

Not only do they spend a lot of money on medical school, but they also put in a lot of time, money, effort, and sacrifice to be trained as a doctor. It’s tough to become a doctor. Then, once you are one, you still have to keep up on the latest advances in your field, and (depending on where you work) put in long, irregular hours. You spend your time among sick, miserable, dying people whose health or life is often in your hands. And you’re doing something that there’s a high demand for but that relatively few people can do. Hell yes, doctors are entitled to get paid well.

You may have a point, but it’s not really a doctor’s job to worry about costs at all. And when people come to him wanting or expecting costly, elaborate procedures or tests, and he doesn’t give them what they expect, and they complain, and he has to say, “Look, I’m saving you money this way”—I don’t blame him for being defensive.

7

Crotalus and weirdaaron have it, I think. The doctor doesn’t come across well, to be fair, but I think it’s symptomatic of a larger issue with profit driving something like health care. It doesn’t work well to have health care be dictated by profitability. Health is not a choice, and the system this doctor works in has skewed the balance away from taking care of patients to ensuring proper revenues. It’s an indictment of the system, really.

8

You realize that this description fits a hell of a lot of professions, including mine (not just acquisition but a VERY specific engineering discipline of which there are VERY few experts but a VERY high demand). The only aspect that is somewhat unique to physicians is the sick, miserable, people etc… No, I don’t deal with them, but people in my discipline deal with a very specific and important capability that, if we weren’t there (we meaning those of us who chose to train/progress into the weeds of this particular discipline), would result in numerous deaths and botched operations by our military and disaster response. I wish I could give you more details to make the comparison more clear but I hope I’ve at least explained enough for you to see that, though docs do face unique challenges and responsibilities in their jobs, other professions face their own critical challenges on which lives/security depends on.

Heck, medics in the Army probably directly save a whole lot more lives in a year in Iraq than a family practioner does in a year in the states and they get paid a low amount, as do most enlisted guys.

9

Agreed. While doctors do deserve to be well-paid, the ones who are most deserving are often not the ones who get paid the best—Army medics being an example.

10

I think the introductory paragraphs of the article nicely lay out his intentions. He points out that

and asserts that, because

there will there will not be enough doctors to provide care for those who are currently uninsured were they to become so. He then provides an example which he feels might be illustrative as to why there is (or will be) a dearth of PPC’s.

Essentially, being a PPO sucks and will suck more in the future because they are expected to provide a very high standard of care to a large (and increasing) body of people while shouldering large financial and legal burdens that could, to some extent, be cast aside were they to enter specialty practice.

He’s not saying he deserves a cut of any money saved by not ordering unnecessary procedures. Rather, he’s pointing out that it would be far easier to just say, “OK” to anyone who asks for an MRI instead of putting in due diligence to determine need.

While this “delay in referral” saves the system money, it also opens him to complaints (and possibly lawsuits) from patients concerned with their own health. Thus, his unpleasant job becomes more so because he is forced to compromise between the interests of the patient (“perform potentially important diagnostics all the time”) and those of the system (“provide costly diagnostics only when it is certain they are necessary”).

When a PPO looks at a specialist they see a guy focusing on a specific thing, seeing less patients, and making a lot more money. Imagine there was a subset of your job that you enjoyed and that you could do that thing exclusively while decreasing your hours and getting a raise.

We need more PPOs if everyone wants coverage and, as a med student, there isn’t much incentive to go that route.

11

This. Also insurance reimbursements continue to fall every year, and doctors (and patients) do not usually like the obvious solution, which is to increase volumes and hurry patients through faster and faster.

12

His “fee” isn’t his salary.

I don’t know what primary care docs get. I would guess 150K give or take…a good salary but not extravagant.

13

Yes, doctors fell entitled beyond reason. Somehow they don’t think it’s greed to want more and more and more at the expense of others, provided they “do good” once in a while.
And they take full personal credit for the discoveries of real lab scientists, even though they may never have personally investigated anything in a scientific way.

And the lawyers I’ve known are worse, because they will feel entitled even when they work for people who they know are on the wrong side of the argument.

14

Any time someone is in charge of a budget. Frequently, the easy way out is to throw money at the problem, and the hard way is figuring out how to do it less expensively. When you have somebody with decision making ability, you want that person to look for the best way, not just the quickest way. This doctor puts in the time with his patients to avoid expensive tests, but is not compensated for that time.

His business brings in that much money, that’s not his personal income. Out of that money he has to pay his rent, staff, insurance, supplies etc, and whatever is left over he gets to keep.

15

Just to fight my ignorance… can you provide an example of a doctor (PPC or specialist) unjustly taking credit from a scientist for a discovery that advanced science or medicine?

16

I agree with what you are saying but I’m only speaking of the circumstance where the doc KNOWS that something is not needed and DOESN’T order it. I’m not speaking of the times when a doc may not know exactly what to do and orders a lab/test that he knows isn’t necessary anyways. You aren’t saving money by not ordering a test that you know is not needed. You’re just being honest and doing your job.

Also, don’t most family practioners gang up with 3-10 other docs and share costs for rent/staff/supplies etc…? Most I’ve seen do.

17

Cubsfan, I think that the problem in perspective that your OP illustrates (not your perspective, but the doctor’s) is that in the health care system, the money has already been paid. The insurance companies have been paid in advance for procedures and medical care. The less care a doctor provides, the more of that money the insurance company keeps, while the patient has paid relatively the same amount of money.

If I worked in a system in which that were the case (ie, my clients have already paid, and I don’t personally realize the benefits of any cost-saving measures due to best practices), I’d either order every test and procedure that was relevant, regardless of necessity, or I’d be interested in getting a piece of the pie that I was baking for the insurance company.

I get what you mean about just ‘doing their jobs,’ but when doing my job well (efficiently) doesn’t benefit me more than doing it in-efficiently, where’s my motivation?

18

First let me disabuse of your misconception about physician income. The linked doc seems to be a Family Practice doc. Their median income is under 150K. Yes after being at the top of their college class and after four years of med school and more years of being paid as an indentured servant working sometimes over a hundred hours a week. Often hundreds of thousands of debt and delayed earning return. Not bad pay compared to many, and a secure job, but no AIG executive, that’s for sure.

As to the work in deciding what not to do. To him all I can say is Preach it brother! Deciding what not to do is hard work. Any newbie can see a patient, hear the chief complaint, stop listening there, order a shitload of expensive tests, and roll on into the next room. It takes effective listening, a good physical exam that tests the hypotheses generated in the history, and the wisdom of experience to know which tests add less than the risks they incur in that particular case. And time consuming communication to explain why discretion is often a wiser option. That cognitive work is not compensated, not compared to doing a procedure or being a specialist who orders the same shitload on all comers without really thinking about it. Doing nothing, but doing it well, is very hard work. Don’t dis it.

19

Ordering the standard tests is robot work. As in many things, the art is in what you do NOT do. As in many of the same things, the payment is not in what you leave out, but in the art.

Non-medical case in point: I do freelance drawings. I am also not a robot and can see where I can save the client money by doing something differently? Does he pay me extra for simplifying his system and causing him to pay less? Nope, but I, as an artist, take satisfaction in that I did it.

I don’t suppose MDs see themselves as artists.

20

I don’t think the quotes you mentioned are related to your OP question, which is: Do we physicians have an unusally high sense of financial entitlement?

The short answer is: Probably, compared with the general public. One key thing to note is that physician income is extremely variable, and the Family Practitioners are at the bottom of the heap. For some, the numbers don’t even make sense anymore, and Family Practice/Primary Care is in big trouble because of this.

First, some numbers: you cannot calculate income by what we charge patients. A typical take-home pay for FPs might be $75-150k/yr for a typical 50 hour/wk work week. That pay starts when you are about 30 years old (4 years of college; 4 years of Med School; 3-4 years of Residency). Your initial debt load is your school expenses (college plus about 30-50k/yr for Med School) plus the buy-in to start or join a practice.

The good side is that you are unfamiliar with the concept of unemployment. You WILL be able to find work somewhere if you are a qualified physician. The bad news is that you don’t start your career til you are 30 and depending on your family circumstances, you may have a significant accumulated debt load. I finished med school back when it was cheap a few decades ago, and I did not pay off my last school debt til I was 40 years old.

Now remember you are not competing in income and status with the masses. You are comparing yourself as a physician with those who were at the very top of their class, usually from high school on. So when you look around and see who is earning what and where they are today, your peer group is typically out in the business world as entrepeneurs and corporate climbers, and they have typically had a ten year head start on you.

That sense of entitlement does not come from comparing ourselves with the guy in our class managing Wendy’s; it’s from comparing ourselves with the guy who is fast-tracking to be the CEO somewhere.

Now the example you quoted in the OP is completely unrelated to a sense of entitlement around income. It’s actually a common frustration expressed toward the idea that there is absolutely no incentive to be fiscally responsible. In fact, most incentivation–particularly around patient satisfaction and outcomes–is entirely related to spending healthcare dollars. That is a much longer topic.

In taking care of about 100,000 patients over the course of my career as an ED physician, I cannot recall a single patient ever thanking me for saving the healthcare system money by ordering fewer tests, less expensive care or any other cost-saving measure. We are focused only on ourselves, and when we are ill–particularly if a third party such as an insurer or the government is picking up the tab–we don’t care what anything costs.

The nature of medicine is such that I can turn a fever and headache into a multi-thousand dollar evaluation by suspecting meningitis or I can reassure you it’s the flu. Should I be wrong I am completely culpable, and should I be right no one knows nor cares. I think that’s the frustration being expressed in those quotes. There is no such thing for us as “knowing” something was not needed.