Bioethics Discussion Blog: Cost and Degrading of Medical Practice: Overlooking, Underestimating Overhead

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Wednesday, July 01, 2009

Cost and Degrading of Medical Practice: Overlooking, Underestimating Overhead

Currently, President Obama is attempting to improve medical care in the United States and reduce its costs. He apparently has spoken to a number of individuals representing the many components of the healthcare system to understand their views of the current system and what should be done to make the system better.I wonder if these presidential discussions dealt with the issue of the financial and even emotional overhead and its effect on medical practice which faces most practicing physicians in one way or another and can influence costs and effectiveness of medical care. Today, I posted a visitor comment on my “I Hate Doctors: Chapter 2” blog thread which I think could easily represent the views of many physicians in practice. Read what was written and I’ll be back at the end.


I hate doctors too... I am one and hate myself for ever going down this path. I spent 10 of the best years of my life training to be a physician (after college). I studied hard to be top of my class, worked 120 hours a week for 5 years during residency, and now have hundreds of thousands of dollars of debt from school loans. Now I've been in practice for nearly 10 years and I wish somebody would have been straight with me about the PRACTICE of medicine. Truths... If I don't see at least 6 patients an hour, I lose money. Overhead is ridiculous. Malpractice premiums are $80,0000 a year (and that's lower than a few years ago, thanks to tort reform - and I've never been sued). In my practice, overhead is about $70,000 a month per physician. So what, physicians make lots of money - yeah, so they can pay staff to file appeals on each claim sent to an insurance company (ever try to get through to an insurance company? no different for a physician's office). You want 15 minutes per visit? you pay my overhead. You think the $29 dollars per medicare visit pays all the staff you see in the office? No pressure to see patients quickly. If I did care about patients I wouldn't have time to show it... (that's a joke - ha, ha)

Time constraints aside, at least 15% of my patients are drug seekers. always nice at the end of the visit for the "can I get some dilaudid?" question. Most patients don't listen to my recommendations and come back 4-6 weeks later with the same symptoms. "Therapy? I use my shoulder all the time at work. I don't need therapy." Oh good, then why are you here? You can obviously diagnose and treat yourself.

If you can't read between the lines, I am completely disgruntled with medicine. I understand why patients hate doctors. Unfortunately with todays system, there isn't enough time to SHOW that I care. Don't think I don't care. Do you think I like seeing the same patient over and over, without them improving? I'm sick of medicine. I'm sick of patients thinking that they are my only patient. Please call me in the middle of the night for the same problem you had the last 3 days. I can only hope the rest of my 8,000 patients call me tonight too. I don't like sleeping. I don't like seeing my kids at night. I love filling out insurance, fmla, disability, etc. forms. I love dictating for 3 hours after seeing patients for 10 hours. I love my patients lying to me, trying to get pain medications. I love patients talking on their cell phone, ignoring me when I come in the room. I love patients not paying their co-pays. I love patients threatening to sue if I don't see them that day.

I love my patients. I love being a doctor.

Lovebeingadoctor


So what does this all say and mean? How would you respond to this physician and the obviously sarcastic ending to the comment? In my own experience, much of what this doctor writes about is true. Physicians are faced with profound financial and emotional investments. Will all of this be taken into consideration when new medical legislation is written? Here is some of my thoughts, perhaps impractical. With regard to the financial overhead, why can’t the government regulate the overhead costs of running an office? Why should the government place the burden of the costs of medical practice along with the income limitations solely on the physician? That is what has been happening ever since Medicare was created in 1965. Shouldn’t the government set limits to what licensed physicians have to pay out to their staff, for the rent, for their equipment and supplies and for insurance? Share the burden for the interest of better care for all citizens. If this is done, I am sure that the emotional overhead will be mitigated and doctors will have more time to spend with their patients, more men and women will find becoming a physician more inviting and will reduce the load of patients each doctor must see and treat. And, well, if patients would become more patient and understanding of the limits of physicians and the medical care system, much aggravation would be reduced on both sides. Do you think they are thinking about all this in Washington these days? ..Maurice.

8 Comments:

At Wednesday, July 01, 2009 6:38:00 PM, Blogger A Kipp said...

As a physician-in-training heading into family medicine, I can certainly understand this doctor's frustrations. No matter how the health care reform changes things, I anticipate the need for some creativity when it comes to payment and reimbursement for me to feel satisfied with my practice. I consider myself a socialist when it comes to government's involvement in people's lives, particularly when it comes to healthcare, but I find myself frightened at the prospect of government involvement in overhead costs of clinics. First of all, those clinics already exist, they are the Medicaid and free clinics, paid for by the National Health Service Corps or other grants. Physicians going into private practice do so for the freedom that entails. I know most practicing physicians don't consider themselves very free these days, but many are choosing to work for public clinics or hospitals for these very reasons.

Frankly, I think having some facet of the government controlling how much physicians can pay their support staff, how much they pay for rent, the supplies they can use, etc a very bad idea. Each physician's practice is set up in a way that works best for that physician, with the right number of exam rooms, EKG machines, and support staff for that particular practice. The administrative aspect of government-controlled (because they won't write a blank check for whatever physicians want to do, there will be reams of paper dictating what could and could not be done) overwhelms any problems we have now, in my humble opinion.

 
At Wednesday, July 01, 2009 9:19:00 PM, Blogger Maurice Bernstein, M.D. said...

The following is from an ethicist who is responding to Lovebeingadoctor's concerns. ..Maurice

Maurice: Our colleague needs some perspective and a recovery of his professionalism.

Perspective first: When I first started out as medical educator, in the fall of 1976 at the then-brand-new and now-very-good Texas A&M University College of Medicine, the introduction to patient course had a reading on the economics of primary care. The article explained that, for a primary care physician to meet expenses, he or she needed to see about 8 patients per hour. The average time a patient spent in an exam room as I recall, was 11-12 minutes with 7-8 of those minutes actually spent with the physician. Back then, insurance companies simply cut checks and there was no managed care and no one telling physicians how to practice medicine.

What's changed? Not the economics of primary care. What's changed is someone telling physicians they have to meet the demands of the economics of primary care. In addition, the historically aberational economics of abundance that the US of A experienced for the 30 or so years after WWII is long over and so every payer in our non-system tries to off-load costs onto other payers through physicians and healthcare organizations. This has increased physicians' administrative costs, certainly a sore point. This is also called accountability.

In other walks of life people train just as long and hard and take greater risks to themselves in their work, e.g., military personnel in combat zones. (Taking care of patients is considerably less dangerous than leading infantry in a fire fight in Afghanistan or landing a fighter jet on a carrier deck at night in a rough sea.) People other than physicians work just as hard as physicians, maybe harder (ask, for example, any dedicated school teacher or dedicated school administrator). Other folks are held accountable in the business world and can be summarily fired if they do not perform. The latter is still very uncommon in medicine. These other jobs often are defined by what Marx called alienation.

Physicians are not made alien from the processes of patient care and their outcomes. To the contary, theu own those processes and experience excellence in dischargint their obligations in the processes of care. This is a rare experience in our economy. The current harshness of our economy should teach us that work that alienates people, and does so for a work life of 40 or 50 years, is dehumanizing. Patient care is just the opposite.

Finally, physcians are very well paid, with the lowest earner more than twice the household median income in the US of A.

Our colleague, and other physicians who make the same, frequent lament, should follow the wisdom of the cloistered orders of the Christian Church and remain silent about the hassles of medical practice.

The professionalism: Our colleagues should then refocus on what is imporant, such as compassion and reaching out to the drug-seeking patient, and be grateful to a society that has invested, and continues to invest, vast sums in medical education (at my medical school, from the state of Texas, about $200,000 per student over four years for Texas residents, not to mention huge amounts of federal and foundation moneys), medical care, and medical research.

Finally, if I were the average hourly wage earner in the US of A (about $14 per hour basically for life given the combination of wage compression and inflation; try conceiving living on this wage and raising a family, much less actually doing so), and heard this doctor complain aloud, I would tell him to get his very own self to Oklahoma.

Larry

Laurence B. McCullough, Ph.D.
Dalton Tomlin Chair in Medical Ethics and Health Policy
Professor of Medicine and Medical Ethics
Associate Director for Education
Center for Medical Ethics and Health Policy
Baylor College of Medicine

 
At Thursday, July 02, 2009 7:27:00 PM, Blogger Joel Sherman said...

A few unrelated comments:
This physician's complaints are at the basis of why there are almost no physicians going into solo private practice anymore. The costs and hassles are just not worth it. Most prefer to go into a clinic or group setting where they get paid either a salary or on some predetermined basis.
I don't understand though his statement that malpractice insurance is $70000 a year. Obstetricians and some other surgeons pay that much, but I never heard of an apparent family practitioner paying anywhere near that.
Doctors do make more than the average salary, but that's a meaningless comparison. Doctors have also spent more than 10 years of their lives training. Most presently come out of training with debts of from $250000 to $500000. They accept tremendous responsibility and work under tremendous pressure. Many skilled laborers make as much or more with a few years apprenticeship and accept little responsibility. A salary of $150000 is not enough to raise a family and send several kids to college without major sacrifices. I don't think Dr McCullough has any idea what obstacles and financial stresses a practicing physician faces.
Who in their right mind would spend 10+ years training in 60-80 hour weeks, to come out with $500000 in debt to make $150000 a year? I have not encouraged any of my children to follow me into medicine.

 
At Tuesday, July 07, 2009 10:18:00 AM, Anonymous Moof said...

Dr. Bernstein, as a patient with multiple chronic illnesses who ends up seeing a lot of different doctors, the overall "feeling" behind some of what I've read really frightens me.

I understand why doctors feel the way they do ... this subject is one that I've been actively exploring for the last 6 years, and it's not new to me, however it still gives me a bout of panic whenever I read about the disappointment and discouragement of yet another physician. I also understand why so few graduates go into family medicine.

Still, when I hear that the system that Obama wants to set in place also include rationed care for those in our country who need the most care of all, and then I realize what a job physicians are faced with ... it makes me wonder what tomorrow will look like in the USA.

We certainly won't have Canadian and other foreign doctors rushing into the US to practice ... we won't have an influx of foreign patients, either ...

In all of what's wrong with medicine, and all of our problems, and how badly healthcare is flagging, we still have the most attractive healthcare system in much of the western world.

That - is a frightening, horrifying thought for someone with chronic illnesses who is also getting old.

I'm sorry if this may not have been completely on topic, but this is what the article and its comments have left me with.

 
At Monday, July 20, 2009 7:48:00 PM, Anonymous Anonymous said...

The doctor who loves his patients and loves being a docotr (NOT), hit on one of the3 things tht I think has caused a great deterioration in medical care. It has caused a very great cost in human suffering from ailments Not caught, it has cost a huge amount in malpractice from both a doctor not having sufficient time to look at and talk to a patient and from patients not understanding what a doctor told them because he had to do so hurriedly.. I think the greatest culprits (besides inflation) are efficiency experts and bean counters as well as lawyers who take cases when they know it isn't justified. Experts (Eks-Spurts = ex = has been + spurt is a drop of water) I do not think they really do much for productivity in any bsuiness, but in medicine..they are praticitng medicine without a license as far as I am concerned... No one but an insurance whoever can dictate treatment without a license. I do not have much sympathy for insurance companies, but I do the docs who have to pay extortionist premiums.. For a while the doctor I saw (I rarely went to a doctor), charged about 1/10th of others, because he carried no malpractice.. and there was even a Big sign on the reception area wall saying so. The reason I went to him was because I knew he was one of the best in my area (by the way I had to drive 200 miles to his office).
leemac

 
At Monday, August 31, 2009 7:18:00 PM, Anonymous Cinque said...

You're kidding right?
$150,000 is more than triple the average pay in this country. Plus, medicine is one of the few occupations that absolutely can not be outsourced. It is high-paying and stable.

If you can't raise a family on that you're incompetent.

Don't you dare try to cry poverty....

If you want more money- handle more patients.

 
At Wednesday, August 15, 2012 9:21:00 PM, Blogger SteveofCaley said...

Medical productivity has gradually fallen under the spell of the productivity spiral. I blame Frank B. Gilbreth.
To maximize productivity in manufacture, one develops a metric of productivity. One then extinguishes the nonproductive actions of the worker for the sake of productive actions.
The more objective the measurement of productivity - widgets per day, for instance - the easier it is to maximize productivity.
Note that what is not assigned a value in the metric, is extinguished.

The hallmark of medical practice in diagnostic fields is the interview. However, using the current insurance systems, the face-to-face interview is nonproductive. It wastes dollars by diminishing the visits-per-hour.

However, in many ways of understanding medicine - and certainly in the mutual satisfaction of the doctor-patient relationship - the interview (history and patient education) IS the centerpiece of value in medical care.

Churning 8-10 PPH is a productivity measure. Seeing 40 PPD hospital patients is a productivity measure. The QUALITY of care is not part of the objective metric.

Also, curse the Devil for inventing "it's not documented, therefore it's not done." The medical chart once was intended to be a succinct summary of the elements in the course of care. Now it is a dumping-ground for irrelevant documentation. The "doctor's note" was once, well, a doctor's - note - about the patient care; a professional stenographic self-reference for later perusal. Now, it is larded down with so much rubbish, that it is a generally irrelevant recitation of many trivial elements of the patient's care, which are absurd. In my field and my job, the production of the visit note takes far longer than the patient visit. I hate that when I'm seeing patients -as well as when I'm treating the chart. Ugh.

"Is your grandmother still dead from breast cancer?" Well, that's absurd, but documentation of the results allows for the higher CPT coding of a doctor's note, I understand. So is, "Did you still quit smoking in 2005?"

Finally, the econometrics of scale play out differently in different fields. The production of widgets may scale up marvelously; but the care of the patient doesn't.

I note, in retrospect, that some data confirms that today's DOCTORS make as much, inflation-adjusted, as REGISTERED NURSES did in 1960.
Much of the illusion that the expense of modern healthcare as being due to the physician's salary, is refuted. If all physicians were forced to WORK FOR FREE, the cost of healthcare would only be diminished by 15%, I understand.

 
At Wednesday, August 15, 2012 9:25:00 PM, Blogger SteveofCaley said...

A PS to anonymous:
"For a while the doctor I saw (I rarely went to a doctor), charged about 1/10th of others, because he carried no malpractice."
Failure to carry malpractice insurance is a felony in my state. They DO aggressively prosecute this crime.

 

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