Are all physicians equal?


Category : Medical Rants

Our current reimbursement system does not distinguish amongst physicians. We live in a socialistic medical system, regardless of what one might think.

If I want to pay more for a gourmet meal I can. If I want to drive a better car I can. If I want to hire the best (and most expensive lawyer) I can. If I want to see the best physician, I may or may not be able to get an appointment. He/she cannot charge a premium for excellence.

This is not the tradition of medical care. If you wanted to see Sir William Osler, you could (for a price).

Why does this matter? Some of my colleagues believe medical care is a right. But we all would like to go to a physician who has a great bedside manner. Many would pay more for such a physician (see the success of retainer medicine).

Scalpel writes eloquently about this problem. Only in medicine can we not increase rates to reflect our overhead. How much is a good doctor worth?

The jerk with the horrible bedside manner who you can hardly understand and who rushes you through your visit receives the same payment per encounter as the kindly concerned physician who takes his time to listen to you. Whether you come to the ER at noon or 3 am, the payment is the same. Pretty scar or ugly scar….same payment. Good results or no improvement….same payment. Nice office or strip center….equal under the law. Welcome to assembly-line medicine.

And even worse, the insurance companies use the Medicare RVUs to set their rates, so everyone is socialized. If the government told all restaurants that they could only charge $10 for a steak dinner, whether they were Golden Corral or Smith and Wollensky’s, what do you think would happen to the quality of the dining experience? Is that really what we want our country to be like?

I wonder if we somehow were able to revert back to a free market system of reimbursement whether the overall costs might decrease, and whether patient and physician satisfaction might improve. It seems like even with the amount of socialized medicine we have now that few are happy with the situation. I think that increasing socialism further is not likely to help.

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Comments (11)

I suspect the concern is incresed costs to patients. I would think, however, based on other industries, costs to the consumer (patients, insurers, etc) would go down on average due to competition.

To address your colleagues: Basic medical care is a right; to provide cutting-edge medical services to every patient without regard to free-market forces would bankrupt the system.

We live in a society where people are willing to pay thousands so there pets can have top-notch care. Why won’t they do that for themselves?

“Basic medical care is a right.”

Really not true at all. Not in theory or in practice. And it never has been, either. This notion is nothing more than a wish. Emergency evaluation at an emergency room is a right, at least in the USA, up to the minimum required standards of EMTALA, as long as that law is on the books and there are hospitals open to be coerced to comply. But no law requires any “basic medical care,” and no law defines what that means.

re: “Only in medicine can we not increase rates to reflect our overhead.”


Try that one out on an automotive parts supplier, or a vendor to Walmart.

Health care is a market in which pricing is dictated by the presence of a small number of large sized, powerful purchasers, i.e., insurance companies and CMS.

re: “If I want to see the best physician …He/she cannot charge a premium for excellence.”

I would expect that the best physician has a fee schedule that charges a rate higher than what he/she actually collects from almost all _third-party_payers_. The fee schedule is almost a complete fiction, in terms of its relationship to what is collected for most services; in real world terms, what a fee schedule captures is the maximum amount that someone out there might pay on an invoice.

But a patient can pay always pay the full fee schedule amount out of pocket.

Your expectations are wrong. The worst and the best physicians have the same fee schedules. The only place where that is not true is acedemia, where they are salaried by the institution and so can get a higher salary for being good. We can charge all we want, but we will all get paid at basically the rate dictated by the insurers, and they do not pay attention to the quality of the doctor (yet).

It seems like DB makes a good case for P4P done right.

Many physicians in my area no longer bill for insurance. These tend to be the best physicians in the area. The patient is expected to submit the bill and pay the difference.

I, for one, choose to go to many of these physicians because they are the best. I willingly pay the difference and submit for whatever my insurance will cover.


A look into the Future:

Very few American-trained physicians (who wants to go into medicine, anymore?) and many foreign medical graduates caring for the patients in this country. We outsource our industries, this is just the reverse. Our best and brightest will not choose medicine as a “vocation” (note – not career). How do you like the idea of a “D” average student tinkering around in your abdomen?

Med mal mediation gone wrong

And mediation confidentiality called into serious question . . . .

(this a soft piece not a legal analysis about a medical malpractice mediation gone awry & mediation confidentiality)

Los Angeles County, I know many neurologists and some psychiatrists who operate on the edge of the insurance world, charging $400-500 for new eval’n then sending a letter to your insurance PMD who orders tests, most of which will be covered by insurance, as will prescriptions. I can think right away of one very excellent physician and one terrible quack that operate this way- both are apparently doing well. They’ve both been around for decades, and both are smooth talkers. An excellent physician new to the area can’t get into this.

The difference between medicine and a restaurant or a clothing store is that no 3rd party pays for your food or clothes. Every healthcare system in the world is financially stressed; most are raising copays, narrowing the list of drugs used, etc.. Given the propensity of US docs to write for the newest brandname drugs adding $30 a month to our patient’s expenses is usually a disservice. This will only get worse because the MBAs and Wall Street control the insurance business and big PhRMA owns Congress. I have two very wealthy friends whose families have done poorly with the high priced healthcare that they got, based on advice from friends and physicians. Medical school grades of my peers have an imperfect correlation with their subsequent skills. There’s no simple answer.

I find my frustrations with medicine have absolutely nothing to do with financial compensation. The truth is that the vast majority of physicians earn are in the top decile when it comes to income. I do find that the daily burdens of insurance companies and the government often work toward sucking the life out of me.

We as doctors and hospitals are partly responsible for this mess. To charge someone $15 for one tylenol tablet is deceitful and offensive. I believe that many docs of the older generation raped medicare when it first came out and that our government intially allowed this so we would all get hooked on the Medicare sugar daddy. Now, the younger docs and American people must suffer through the great American healthcare debacle.

As far as I’m concerned, the ONLY solution to make medicine a great profession once again is to get rid of the 3rd party payor system. Have people pay cash for their primary care and if they want they can get catastrophic insurance in case things get really bad. The phsycians would then actually have to charge what they are worth rather then what the government tells them they can. Some will be able to charge more while others will have to charge far less.

I believe with all my heart that the overall cost of healthcare would plummet dramatically without the 3rd party payors, and that physicians as a whole would be a happy bunch. Where is the AMA on this or the ACP or the SGIM? Sadly, they appear to be in bed with the same people actively socializing and destroying our field. As physicians we need new representation and a completley different vision for the future.

Maybe I am not reading into your post correctly, so allow me to rant a bit. I am worried about your proposal that “the ONLY solution to make medicine a great profession once again is to get rid of the 3rd party payer system.” Is this solution that you propose, being of “benefit” and doing “no harm?” Shouldn’t the medical profession not only worry about reimbursement and status of healthcare in the US, but also that of the world? What will your “solution” do for the poor? Or, as it sounds, will it only pad your account (ie “if they want they can get catastrophic insurance in case things get really bad,” what does that prove/provide)? To me the ONLY solution to making medicine great is to provide services to all, addressing healthcare from Boise, Id to Al Fashir, Sudan. I understand that we need a revolution in healthcare today, but that revolution should include and embrace those who cannot “pay cash for their primary care.” If you are in fact not concerned about money (I find my frustrations with medicine have absolutely nothing to do with financial compensation) then why not provide a solution that is better for all? While reimbursement, malpractice insurance, P4P is an issue I feel that there are bigger fish to fry in medicine today (check out because after all, as you said, “The truth is that the vast majority of physicians earn are in the top decile when it comes to income.”

DB: What a breath of fresh air! I’m embarrassed that I’ve discovered you so late. I will be back when I have more time and will comment on other posts of yours.

PH: Absolutely right. I wrote about that here.

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