Why have doctors been given a pass in the healthcare debate?

Great Debates
1

Most of the coverage of this issue seems to (deservedly) talk about how badly the public is being fleeced by lawers, Pharma, and big insurance companies, but the doctors get a pass. Why is that the case considering doctors are just as culpable. Consider the following:

I. 100k people die every year from infections picked up in a hospital. Obviously, not all of these death are avoidable, nor should they all be blamed on doctors, but there is culpability there. Keep in mind that fighting these infections costs between 4-29 billion anually, not including the resulting lawsuits and legal fees.

The most glaring example is the story of Peter Pronovost. This doctor created a simple list of things doctors should do to dramatically reduce the number of infections.

Looking for a reason why these protocols have not been instituted everywhere? The common reasons researchers give are the following:

  1. Many physicians do not like being monitored by nurses or otherwise being forced to follow a checklist;

  2. A wish to avoid standardized tasks and bureaucracy; and

  3. A focus by researchers on “more exciting” issues such as disease biology and new treatment therapies

In response to much of what’s listed above, Pronovost said the following:

So we are wasting billions of dollars, and killing people because doctors don’t like being told to follow a checklist.
II. Pharma essentially bribes doctors to prescribe medicine. We only hear about the most egregious examples, but the subtle influence is there. Even JAMA says doctors should stop accepting bribes. Drug companies spend 13k per doctor per year to influence their habits (20+ billion/year). This is all reflected in the costs of medicine to the consumer. We subsidize their dinners and golf outings, and in many cases, are told to get drugs and treatments that are less effective or unnecessary. JAMA said, “doctors in teaching hospitals should lead the way in refusing to take gifts from the pharmaceutical and medical device industries, because it damages the reputation of the profession”.

III. Doctors are often crappy business men who offer really crappy customer service. I can do almost everything online, except make an appointment at my doctor’s office. I get there at the scheduled time; I wait, then I go to wait in a smaller room. There is almost no adherence to the schedule.

Many still give sloppy, hand-written prescriptions that often create more work and confusion. Why has their customer service not advanced at the same rate. Why aren’t their records computerized in a uniform fashion?

Doctors also haven’t done much to collectively lower their overhead. Many complain about how they must hire people to bicker with insurance companies all day just to get paid. However, I don’t see many of them trying to streamline the process through collective bargaining. In states where there are multiple insurers, why don’t doctors collective bargain so that they have more power than any one insurance company?

IV. Doctors (via the AMA, et al.) limit their numbers. They even stopped opening medical schools for years because they thought there would be too many doctors. Why shouldn’t the market decide? Furthermore, they don’t discipline the bad doctors. About 5% of all doctors account for 54% of malpractice payouts. Only 8% of doctors (1 out of 12) with 2 or more malpractice payouts have been disciplined by their state medical board, and only 17% of doctors (1 out of 6) who have made 5 or more malpractice payouts have been disciplined by their state medical board.

V. Doctors often take the easy, costly way; caving in to defensive medicine advocates and whiny patients. The problem goes further than just prescribing unnecessary antibiotics at the expense of public health. Doctors prescribe medicine and order tests just to avoid hassle or a lawsuit. Some firms have stated that more than half the 2.2 trillion dollars we spend on health care is wasted.

There is tons of compelling evidence that not ordering those test, etc. would have few measurable health consequences, and that not doing so would ultimately save boatloads of money even if lawsuits increased. Yet, common sense does not prevail.

I think we can all agree that doctors are generally good folks who provide a vital service, but their hypocrisy and complicity in health care fraud needs to be pointed out. Ultimately, doctors need to be the stop-gap that prevents consumers, producers, and middlemen (insurance companies) from ruining things for everyone else. They have failed to do so in almost every respect.

2

Lots of doctors buy up testing labs and run their patients through them. Oddly they seem to need a lot more of the tests they make money off than the stats would indicate are needed.
One third of American doctors are over 55 years old. We will have a real big shortage soon.

3

I. Not all doctors are in the ER. Narrow your focus a bit on that one.

II. Golf is gone. Dinner is now limited. The Dinners serve to give the Docs information, along with the steak. If you kill the dinners, you had best have a suggestion of another way for the Docs to easily get information on new meds.

III. Docs are not trained as businessmen, and we yell at them when they try to act like businessmen. Now you yell at them for NOT acting like businessmen. Appointments are jacked due to the fact that the typical GP is paid for 7 minutes, including paperwork time. However, if they spend more time the schedule is fried. The system is designed to be messed up due to the complicated nature of the game. It sucks, and unless you go down the concierge care route - you won’t see an improvement.

III. part two. Docs can’t collective bargain - they run into anti-trust laws are accused of price fixing.

IV. AMA does limit, though we allow foreign docs in all the time so I don’t know how relevant that is anymore. As for malpractice, you would need to determine how many of those were settlements first. Many insurance companies will force a settlement rather than fight. Docs might not lose their license, but if they can’t get insurance they are as good as done regardless. I know two OB-GYNs that were thrown under the bus by their insurance companies and can no longer practice.

V. It is called defensive medicine for a reason - it slows down the lawsuits (they hope/think). If you don’t order the test, and this is the 1%, then the first thing when your ass hits the witness stand is, “Why didn’t you order the test?” I don’t claim that Tort reform is a panacea, but there are certainly docs who over order tests just to be sure that they are covered. FYI - I was one of those 1% folks once, and I was happy that my doc ordered what should have been a excessive test.

4

Some payments are tied to the test, with minimal reimbursement for interpretation. If you outsource the test, you get nothing. If you do the test yourself, you can make money.

5

Apparently the collective coverage you and I are reading differs but in my experience most of the pro-reform push this time around has been talking about how badly the public is being fleeced by insurance companies, largely ignoring everyone else. I would say that malpractice lawyers, the pharmaceutical industry and doctors/hospitals have all been spared a lot of attention. I think this is for 2 reasons 1) the reform being proposed is actually predominantly about the health insurance practice. In spite of the dirty lies nobody is talking about the government forcing doctors to treat people according to its whims. And 2) The biggest hospital groups, the AMA and PhRMA were all smart enough to side with Obama and only the health insurers are getting people angry by lying to them about murdering grandma and other manufactured astro turf.

6

I am looking at a bill from my last doctors visit and the follow-ups.

$315 for an annual physical (less than 15 minutes with doctor)
$95 for EKG (done by Nurse)
$85 for EKG interpretation (I wasn’t there, nothing was communicated back to me except the bill)
$1102 for nine tests. One ($700) done by a doctor, who spend about 30 minutes with me. It took about 5 weeks to get this test scheduled. The guy is booked solid, eight hours a day, five days a week.
$180 for interpreting various tests done by the doctor (I had to call three times for the doctor to speak to me about the test results)

Total $1177, reduced to $547 by my insurance, out of which I paid $477, $400 for annual deductible, $77 for co-pays.

I changed from insurance that used to pay for virtually everything at 100% to insurance with a deductible and % copays for everything other than doctors visits, which are a flat $25.

You bet next time I am going to ask the doctor to explain exactly what he expects to do with each test, the significance of each, and if he doesn’t give me answers I am satisfied, I will be looking for a new doctor. When I had more comprehensive insurance I didn’t care. I have borderline hypertension, but no other health issues. Damned if I know why I needed all those tests. Maybe the doctor had a boat payment due.

I’ve said this before on two threads. I don’t buy the cries of poverty from PCPs. I have a cousin who is a PCP. He spends much more time on tax “planning” than on keeping up with his profession. His continuing educations choices are thinly disguised vacations. Another PCP plays on my tennis team. His house and car are fabulous even by our relatively affluent standards. He has more free time than any other working professional I know.

Maybe we can solve the doctor shortage by lowering physician compensation. They will be forced to work longer house to make their $250k per year. Boo hoo.

7

They outsource to the lab they own. They schedule a ton of tests and collect both ways.

8

Note that as a general rule, it’s illegal to bill Medicare for referrals to a lab where the doctor has a financial interest. There are a lot of permissible exceptions, however.

9

If we’re ever going to fix the health care crisis in this country, this is something that definitely needs to be addressed. Doctors in countries with socialized health care don’t earn nearly the salaries that American doctors make.

10

The OP might find this articleinteresting.

11

There are a host of things wrong and dysfunctional with the American healthcare system.

Medicine has become increasingly effective and increasingly dangerous at the same time.

From my perspective as a physician, the current mess is exactly indicative of what happens when big government tries to make anything work. That is of course a personal perspective, but medicine has more regulation and regulatory bodies than anything I know, and look at the result…

I have a personal opinion of what the various issues are, and you touch on some of them. However I think the current “healthcare debate” involves trying to find mechanisms to broaden coverage, not reduce cost or increase efficiency or improve care or caregivers. It is not fundamentally a debate about what’s wrong with the healthcare system itself (other than how to pay for it).

It is for this reason–putting the cart before the horse–that I think all the current efforts completely miss the point about what is wrong with healthcare. We are taking a bizarre and overly complex healthcare system and expanding it mindlessly. Nice.

You may be surprised to learn how little control doctors have over healthcare delivery and how plenty annoyed most of them are at the current system.

12

The current debate over healthcare has all of its focus on finding a way to get care for those who can’t currently afford it. Good ideal except that part of the reason so many can’t get the healthcare they need is because the system is so broken and needlessly expensive. **Chief Pedant ** sums up my opinion very nicely. Any reform of healthcare in American needs to focus on fixing the system, not just finding more money to pour into it.

While the amount of money doctors make does kind of stick in my craw, that isn’t where the real expense of healthcare is. Check your bill at a hospital sometime - $10 for a cotton swab, $50 for the little package with the plastic water pitcher you cannot refuse… This stuff is mostly hidden and adds up to huge amounts.

13

I’d like more information on this. I googled, but the first few links didn’t tell me a whole lot. Do [AMA, doctors, someone else?] argue that increasing the number of doctors would lower their quality? That is, are there not enough qualified candidates? AFAIK, the non-complete rate in med school is pretty low, i.e. there are few “admissions mistakes”. I think the difficulty of medical training gets exaggerated, given the tales I’ve heard (anecdote warning) from chemistry MD/PhDs and chemistry grad-school-dropouts-now-med-students who have experienced both worlds.

14

The reason is purely economic. By limiting the number of doctors, they keep salaries of doctors high.

This is a very common form of regulatory capture. Many of the regulations you think are passed to help the public are actually passed to help existing special interests erect barriers to entry for others. You see it in building codes, where many regulations are set up simply to prevent pre-fab manufacturing and force the hiring of plumbers and electricians and such. You see it in certification standards that are needlessly complex, and faculty entrance requirements which demand unreasonably high grades. You also see it in regulations which require increasingly high levels of education for the same job.

For example, it used to be common for working nurses to have a one-year diploma. Then came the 2-year RN diploma. Now a lot of jurisdictions require four-year degrees for nurses.

In education, the teaching certification requirements are becoming increasingly byzantine and arbitrary.

All of this is done with the approval of existing professional groups and unions, or even at their behest. Because of course, current members are always grandfathered in when such changes are made. The rule is, get in the door, then slam it shut behind you before anyone else can come in and compete with you.

15

Who is “they” and how are “they” doing this?

Over the course of my career as a physician, I’ve interacted with hundreds of doctors. I’ve never heard this expressed directly or indirectly, in public or in private, by any physician. There is some sort of secret cabal to limit our numbers? A quiet conspiracy, perhaps, of which none of us are aware?

I’ve always assumed that states and/or the Federal government might create a drive to increase the number of doctors in some way, but I guess I actually have no idea. I don’t think most physicians are actively agitating for more doctors, but neither are they conspiring to limit them.

I would be willing to bet, however, that increasing the number of doctors simply increases the total cost of healthcare without having much effect on improving it. Another thread, perhaps. I am unaware of instances where bringing in more physicians lowered the cost of healthcare, and in fact I’d guess physicians tend to concentrate where the paying patients are rather than any other single driver. I am reasonably sure the least expensive care (in terms of physician charges) is probably in rural areas where the physician supply is also the lowest…

16

This sentence can read two ways. It confused me at first.

But I take it to mean, “In spite of dirty lies on the part of reforms’ opponents, no one in Congress is planning to have government force doctors to treat people according to its whims.” Right?

17

In our state NajaHusband, biology PhD, isn’t “qualified” to teach high school bio. Two years of unpaid servitude, $30k and a teacher’s union card would fix that, though.

18

Someone commented that the AMA doesn’t do much to discipline docs. I am not aware of any professional groups or unions that do more the lip service in the disciplining of their members. This is teachers, cops, firefighters, brokers, attorneys, etc.

Stopping the bad ones will always come from outside.

19

Really? Protecting your own always comes before collective integrity? You’d think internal policing would be the most effective, that good doctors (cops, etc.) would stand up against the bad ones the strongest. I would think they’d be the most sensitive about what it means when one of their own fucks up; even if only to avoid guilt by association.

20

The AMA is a voluntary advocacy organization for physicians. It has no power to discipline anyone. That’s up to the state medical boards, who can and often do discipline physicians who act irresponsibly.