With health care expenditures being more than one-sixth of the GDP and Medicare being 20%  of this (and Medicaid another 15%), it’s clear that we ignore the precarious state of our government’s foray into the arena of health insurance at our own peril. It’s no wonder that Medicare and Social Security, the two largest entitlement programs, have been described as the “third rail” of American politics. When people get more than they’ve paid in, they’re understandably reluctant to have it reformed. One of my associates, unfortunately faced with an illness requiring expensive medical treatments, gushes about the munificence of the system, and in the next breath laments its unsustainability. For, as with Social Security, the numbers paying in are dwindling compared to the aging recipients. It’s not that this wasn’t predictable, it’s just that “fixing” it was unpalatable. Since I’ve discussed this at length in previous rants on the health care debacle, I don’t want to belabor the point. I’ll direct the reader to past rants describing the specific steps required to turn things around.

What I did want to address is something to which I gave short shrift—the disparity in compensation throughout the medical profession. When pushed against the financial wall, the government tends to use a club rather than a scalpel, and the private insurers will likely follow Medicare’s lead. The analysts look to see where the most volume is in terms of procedures and lop off a healthy percentage. Now, medical fees, in my opinion, are a hodge-podge of historically-driven numbers influenced heavily by non-market forces, that have become progressively distorted. Minor office procedures that can be done quickly are reimbursed more heavily than long, complex medical visits. Open heart surgery, when adjusted for time and skill, is treated more casually than fixing a hang-nail. Physicians, myself included, are reluctant to spotlight this disparity because of the tendency of the government, and insurers in general, to simply cut everything more.

What needs to happen is reasonable reimbursement for skill, stress, and time at risk. I wonder if most people realize that the physician who rousts himself to deliver care at 3 a.m. gets the same reimbursement as 3 p.m. Many patients are unaware that the doctor they see in the middle of the night isn’t a shift-worker. While the emergency room is staffed this way, most physicians have to present for work the next day after a nocturnal emergency. We need to stop cutting compensation for acute care, augment services provided after-hours, and reexamine reimbursement for less urgent, less skilled interventions, or we’ll find fewer and fewer takers for the high-stress, “inconvenient” jobs in medicine.


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