Wednesday, June 4, 2008

Those evil surgeons

I've been wanting to write about this for a while. Recently, the Wall St Journal Health Blog highlighted a letter the American College of Surgeons sent to MedPac, the advisory group that makes recommendations to Congress with regards to Medicare funding. Essentially, the ACS objects to a plan to raise Medicare pay outs to primary care physicians in a "budget neutral" manner. What does this mean and why is the surgical community outraged? Because "budget neutral" is a code phrase for "take money from from those evil, greedy surgical specialists and give it to the family practice docs".

The headline of the WSJ article is frankly disingenuous. Surgeons aren't opposed to primary care docs getting more money. We're all for that. But don't obtain that funding from the already dwindling surgeon's piece of the pie. Many surgical procedures have seen reimbursements cut 40-60% over the past 20 years. And that's not an adjustment based on inflation; those are real, bottom-line dollars. If you want all specialties to be paid the same, that's fine. But if that's the case, then we all better share in the liability and the risk. You want part of my earnings? Then make sure we all pay the same malpractice premiums. Oh, and make sure that I get paid like an attending during my fourth and fifth years of residency and any additional years of fellowship I might pursue, to ensure my salary is equal to the family practice doc from the get-go. It's all about equality, right? It would only be "fair".

I believe Sid Schwab touched on this earlier, but it bears repeating. This is a perfect scenario for the federal government and the insurance companies: doctors from different specialties fighting each other for the piddly scraps of revenue that they decide to dole out to us. I don't need to write a treatise to defend the concept that some specialties ought to be paid more than others. It would be insulting to everyone's intelligence. Let's get beyond that. Primary care certainly needs to be better remunerated. Being forced to see 50 patients a day just to break even isn't a sustainable business model, nor is it good medicine. But the fault doesn't lie with the surgeons. We're right there in the trenches with you.

As an analogy, imagine major league baseball without a players union or a collective bargaining agreement. Owners with their multi-billion dollar TV contracts could dictate player salaries to be whatever they chose. Maybe the power hitting first basemen gets a lucrative contract because he produces and is a gate attraction. But what about the slick fielding shortstop who steals a lot of bases and hits for a high average? Maybe he doesn't hit a lot of homers, but he is arguably just as valuable as the first basemen. It wouldn't be fair to pay him a pittance for his efforts. Would he begrudge the power hitter his salary? Of course not. He might be jealous, but he would never demand that the first baseman fork over a portion of his salary to "make things more equitable". He knows the owner is sitting on a pile of cash. He'd call the owner and say, Pay me what I'm worth, dammit.

There's plenty of money to go around. The discrepancy in pay between the GI doc and the PCP is not the reason why health care is so expensive. The giant HMO's and the pharmaceutical conglomerates would love to have you believe that. There's a reason both are multi-billion dollar industries. Let's not nickel and dime each other. A united front is our only hope of ensuring that the backbone of the American health care system, i.e. the physicians, does not deteriorate into a collection of second- rate, infighting, backstabbing special interests.

18 comments:

rlbates said...

Thank you for putting this so well. I tried, but have not been happy with my efforts so left it unfinished.

Anonymous said...

Escept of course, in a lot of sports there are team salary caps, so salaries really are a zero sum game within a team.

MedZag said...

Completely agree with your thoughts. Unfortunately, physicians are too busy trying to tread water to pour energy into a unified front, and we lack the methods to effectively campaign against Big Industry - both monetarily and ethically. Physicians would never agree to anything as drastic as a stoppage of work, because such action would be unethical and damning to our patients, but we lack a plan B of the same magnitude to garner public attention and support. At the same time, physicians lack the financial clout to put pressure from the other end of the field in congress. I wish I could see a solution, any solution, to the situation that could work within the free market model. But it just isn't coming to me.

Buckeye Surgeon said...

Anon-
You're assuming that the teams all use up all the money that the salary cap allows.... not always the case. Cheapskate owners (Florida Marlins, Memphis Grizzlies etc) will keep the payroll way below the cap line to enhance their own take home net.

J. said...

Buckeye, I'd be interested in getting your perspective on this: http://www.slate.com/id/2190273/
I can tell you that the top issuer in our state pays out 93 cents out of every dollar in claims, but it is also a nonprofit (I struggle to make sense of shareholders being financed off the backs of ratepayers). From a government perspective, I can tell you that sources of revenue are shrinking while enrollment in our entitlement programs is growing. With over 50% of our budget (small midwestern state) going toward state aid to education and Medicaid, and every provider that I've talked to agrees that we still live in a high tax climate state, the question is where do the additional dollars come from?

Anonymous said...

Unfortunately, I think surgeons will lose out on this, as the primary care physicians are adored much more than surgeons. Ultimately, public policy and opinion will determine this outcome and specialists will probably lose the battle, since primary care are the "underdogs" in medicine. And everyone cheers for the underdog.

Anonymous said...

"If you want all specialties to be paid the same, that's fine.... ... to ensure my salary is equal to the family practice doc from the get-go. It's all about equality, right? It would only be "fair"."

Where the heck are you getting this? That's just a straw man and you know it. I haven't seen anyone propose pay equality and we certainly aren't asking for that. Every family/IM/peds doc I've known went into this knowing we'd make less than the specialists.

The problem is that:
1. Generalist pay is becoming too low to stay in business and raise your family, at least in our area where we're dropping like flies.
2. Medicare has cleverly set us on each other with this 'salary cap'.

Many of us that care about generalist medicine are busy planning our post-Medicare practices, not dreaming of making specialist level incomes. Soon, you can fight with the midlevels doing Medicare's primary care about your pay.

Buckeye Surgeon said...

Anon-
I would only say that you need to read my whole post. I don't like the idea of intra-physician bickering over scraps like we're a bunch of pigeons at the park. My objection was to the none too subtlely implied tone of the WSJ piece: "Surgeons oppose pay raises for PCP's".... give me a break. That's a distortion and you know it. This can work. We just have to change the public's perception of what the real underlying cause is of our astronomical health care costs: $10,000 MRI's for back pain, putting patients on the latest hypertensive pill when the cheap generics will work just as well, spending 5 grand o day on a 88 year old demented patient in the ICU....

Anonymous said...

Buckeye:
I think you need to differentiate between "what medpac thinks" and what "primary care docs think". I haven't met very many PCP's who think they deserve surgeon wages. I do think the present system is not sustainable on all fronts. The PCP's will just go under first. You did bring up a good point about insurance co's and pharma industry. What man is worth 1.6 billion (the former united CEO), especially when his company's plan is considered a giant piece of shit by most docs. Why did our moron of a president specifically make sure that the government could not bargain as one entity when it came to medicare D (like the VA, one of the few good things about the VA)? Because of pharma lobbyists. We docs don't stick together (or are not allowed to stick together thanks to anti-trust laws) and we all get fucked because of it. Right now, the ones on the bottom of the pile are the PCPs. There is no KY at the bottom.

Anonymous said...

Buckeye:
I think you need to differentiate between "what medpac thinks" and what "primary care docs think". I haven't met very many PCP's who think they deserve surgeon wages. I do think the present system is not sustainable on all fronts. The PCP's will just go under first. You did bring up a good point about insurance co's and pharma industry. What man is worth 1.6 billion (the former united CEO), especially when his company's plan is considered a giant piece of shit by most docs. Why did our moron of a president specifically make sure that the government could not bargain as one entity when it came to medicare D (like the VA, one of the few good things about the VA)? Because of pharma lobbyists. We docs don't stick together (or are not allowed to stick together thanks to anti-trust laws) and we all get fucked because of it. Right now, the ones on the bottom of the pile are the PCPs. There is no KY at the bottom.

Anonymous said...

anon 7:29.."I haven't met very many PCP's who think they deserve surgeon wages."

You don't read many PCP blogs, do you?

Anonymous said...

Acutally anon 04:19 I do. I was once a general internist (now a medical subspecialist). If you think reading what a handful of disgruntled PCP's on kevin MD is what "most PCP's" think, then you really have very little interactions with your patient's primary docs (your loss). I interact with them daily, like all the rest of us their reimbursements are dropping (even when had flat as has been done for essentially the last decade when inflation is taken into account). The problem is they are on the bottom of the pay totem pole. They are the first to go under. I can't tell you how many former PCP's who have become minute clinic docs, rural ER docs, hospitalists, or just plain retired. I have essentially (by default) become a PCP to more than a few of my patients because their doc is gone and they can't find a another. I can do it because I used to be one, but frankly most surgical/medical subspecialists can't. I saw the handwriting on the wall about primary care a decade ago...hence my own decision. When I was a primary internist I never expected a surgeons wages. I also did not expect ever decreasing wages necessitating either plugging in ever more patients to the same hours or laying off staff. That's the fact. A bigger question is, why are doctors, who comprise 20% of all medicare reimbursements, expected to take the brunt of all the cuts? WE COULD ALL BE CUT TO 0% REIMBURSEMENT AND THE SAME PROBLEMS WOULD STILL EXIST. Why did George Bush allow medicare D to be a giant slush fund for pharma? He could have just as easily have been a proponant of a VA type negotiating structure for drugs which would save a hell of alot more money than the 10% cut that stark et al are advocating this summer. Why did the former CEO of united walk away with 1.6 BILLION in compensation, when he runs a plan that I and every other doc I know thinks is a peace of shit. I do agree with buckeye here that medpac/insurance company's/medicare are advocating a divide and conquer strategy on docs. Two years ago it was oncology, last year, rads, this year surgeons. Until we start sticking together (at least in spirit thanks to anti-trust laws) and tell them to all go fuck themselves, we will be the ones getting fucked.

Anonymous said...

To the anon physician directly above this comment. I am not the person you were responding to, but rather I am a patient who wanted to comment to you about one of your remarks.

The idea of many of the physicians who comment at Kevin MDs being disgruntled is head on. I read him for a couple years and finally, about a year ago I had to stop reading there at all. The reason is because it was beginning to effect my relationship with my own doctors. I have never had anything but good productive relationships with my doctors, and yet, reading what most of these guys at Kevins think of patients, and how they hate us, made me begin to look at my own docs through different eyes. I was doubting them, and seem to be all of a sudden, on the defensive when I would have an office visit.

Then reality set in, and I realized these guys are not a true representation of the medical community as a whole. There are many many good caring and compassionate doctors still out there. Thanks for pointing this out for us.

platensimycin said...

boy, our country indeed seems more divisive than ever, even within medical field. i wonder why....

abusive system? inadequate pay and/or rest? cranky customer or staff? all of the above?

Anonymous said...

What should average Joe PCP make, and what about average Jane surgeon?

Why do our doctors need to make three times more than European doctors?

Just asking.

shadowfax said...

Buckeye,

I'll develop this more on my own site when I get a chance. I agree with the "common enemy" and "house divided" themes you raise, but I also, having spent a lot of time working on reimbursement issues, feel very strongly that many procedures are grossly overvalued compared to the cognitive services.

Note that I am not saying that "surgeons are paid too much," nor am I saying that "cholecystectomies are over-reimbursed." I don't know how much a gallbag is worth now, or how much it ought to be. But, as I have blogged about before, a wide variety of procedures are ridiculously over-valued. Remember this: a complex facial laceration or fracture care for a ankle fracture are worth more than an hour of critical care time. Can you defend that as just and valid? Cause I can't. This is, I think, a consequence of the methodology the RUC uses to determine physician work. It is true that if a different standard were adopted, some physicians who currently are well paid would see their incomes shrink. Frankly, I would find that a fair and equitable outcome. Which is not to say that a GP should be paid the same as an orthopedist, but the current differential is artificially high. More to the point, the current methodology gives proceduralists a heavy motivation to, well, perform procedures. You know the old saying, if you go to a barber you get a haircut; if you go to a surgeon . . . you get an operation.

And finally, this is a zero-sum game. Actually, it is a negative sum game. Medicare is like $400 billion now, unfunded, and thanks to W, the general budget is broke. Huge tax increases would be needed just to balance the budget, let alone continue the current rate of increase. If the PCPs are going to be brought back up to market, it'll have to come from somewhere. Ugly but true.

platensimycin said...

Health care expenditure doesn't always need to go off the chart, after all. As it turns out, the treatment culture, strategy and "aggressiveness" (as Consumer Reports put it) vary widely from state to state. Please feel free to check out the following:

"Too Much Treatment?" pg 40-44, Consumer Reports; July, 2008.

Dartmouth Atlas of Health Care study (www.dartmouthatlas.org)

Anonymous said...

Dude, you guys make a ton of money as it is. All doctors do. Just look at at the BLS stats or maybe your car or house? Don't get greedy, man.