The Doctors

I’ve stated I’ll lambaste everyone, including my own kind, and will remain true to my promise. The single biggest puzzle piece in the problem that is the health-care industry is the doctors. It isn’t physician salaries, which, as I’ve previously pointed out are no more than 20 percent of health-care expenditures. It is we, the physicians, who determine how the billions of heath care dollars should be spent.

Up front, I have to state that the president’s characterization of physicians in general (doctors doing tonsillectomies willy-nilly to make a buck) is insulting and likely reflects a generalization of his own background in Chicago politics. And his perception of physician reimbursement shows a surprising ignorance of reality. ($70,000 for an amputation? Really.) That said, I don’t think any honest physician would deny there is a lot of over-ordering of medical tests, imaging, and probably specialist consultations (in the net; I’ve also seen circumstances where earlier referral would have saved morbidity and cost). My colleagues would probably disagree as to the relative importance of the various incentives for this sorry state of affairs, and would also likely view themselves as innocent bystanders. Dishonest physicians, of course, contribute to the problem like leaks in an ocean liner. But while it is logical to assume crooks, relative to their numbers, do a disproportionate amount of damage, I believe that in absolute cost, the normal, honest, professional doc just trying to do a good day’s work shoulders most of the blame.

For the sake of discussion, let’s assume one in a hundred physicians is dishonest (in my experience in several practices on both coasts, I think it’s far less; I’ve found most physicians I’ve had the privilege of working with to be of solid character). And by “dishonest,” I mean knowingly trying to game the system for financial gain. This so-called “businessman physician” is generally known to the medical community at large as such and shunned as being out of the mainstream.

So, if I’m right, and at least 99% of physicians are honest, why are costs so high? I would target three overriding factors: the legal system, practice patterns, and patient expectations. Obviously, the three areas often intersect.

I referenced the legal system in a prior blog, but the subject deserves a brief revisit in this context. The impact of fear of litigation is easy to understand. A fair system of redressing grievances for negligence and medical malpractice is important in a just society, but escalating awards for vague concepts such as “pain and suffering” have led to a lottery system where personal injury attorneys get substantial chunks of huge payouts, one of which can make them wealthy for the rest of their lives. This in turn begets huge malpractice insurance premiums (except in states like California and others where tort reform has been instituted) and a “look over your shoulder” attitude on the part of care providers. Based on a good history and physical exam, a doctor may be 95% sure that something is benign, but by ordering an expensive test, can drive that to 98%. And if he fails to order that test and gets sued, the patient’s lawyer will certainly cite the “omission.” What does it cost the physician in the cross hairs to order this “insurance policy”? Nothing. What does it cost the system in the aggregate? Plenty. We all pay a price for being one of the most litigious societies.

 

NEXT: The Doctors—Practice Patterns and Patient Expectations

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