Maggie Mahar Answers Viewer Questions - Part II
We'd like to thank Maggie Mahar for agreeing to answer viewers' questions about the health industry. Below, in no particular order, is her second set of answers, while her first set of answers can be found here.
Please note that the views and opinions expressed are not necessarily the views and opinions held by Bill Moyers or BILL MOYERS JOURNAL.
Q: A recent writer complained that she had paid "I think" 50 dollars for a two minute visit with a doctor who gave her a shot. Firstly, I find it hard to believe that a doctor spoke with her, probably took x-rays, and then gave her a shot in two minutes. Even assuming the doctor lunged at her with the injection as soon as he came in the room and the visit really did take 2 minutes- I'm not sure what her complaint is. Should she have been charged 10 or 20 dollars for an injection by a physician. Perhaps she would like to have paid in pennies.
Maybe I'm the one that is wrong, but yesterday I had an electrician over to my house. He charged me 200 dollars for ten minutes and he didn't even fix the problem. I paid him and thanked him for his time.
My point is that I believe some people have unrealistic expectations regarding personal health care costs. I realize doctors are held to a very high standard, but I never complain about their compensation. My wife had cancer and I paid all our copays and deductibles without a complaint. It hurt, but I was so happy to have trained doctors and nurses who could (and would) help us. I'm sure we have all had bad experiences with doctors, but on the whole I think we should all be careful what we wish for. Doctors could very easily opt out of all insurance (as many already have started to do) and charge whatever they want. Then there would really be a disparity in health care. Furthermore, if we continue to target doctors there will be less doctors staying in medicine. Why would anyone want to be in a profession where people complain about them, call them at 3 in the morning asking for their help, and then not want to pay them (and maybe even sue them)?.
Lastly, I hate to be too harsh, but to put things in perspective I'm sure most doctors make less than Mr. Moyer and probably about the same as most lawyers.
A: Doctors’ pay varies widely by specialty. High-end physicians (neurosurgeons, orthosurgeons, urologists, radiologists, cardiologists) can make $500,000 to $850,000 a year—or more, sometimes much more--while physicians responsible for preventive and primary care (family docs, internist, pediatricians, palliative care specialists and psychiatrists) may earn as little as $115,000, and can expect, at the high end, no more than $275,000. Even ER docs — who may have your life in their hands — make only about $150,000 at the low end of the scale. (These numbers do not include bonuses or benefits—doctors who work for medical centers and other large entities often receive malpractice insurance as well as health benefits.) I’ve posted about this here: http://www.healthbeatblog.org/2008/01/health-care-spe.html.
Overall, we pay doctors more if they cut you or irradiate you, less if they talk to you and listen to you. We reward more aggressive, intensive medicine. This is in part because many specialties require more years of training, and when students emerge from that training they have tens of thousands of dollars in loans. (Other countries subsidize the cost of medical training; we don’t. Though the House bill currently under consideration would provide substantial loan-forgiveness for doctors who go into primary care, and Medicare would hike fees for primary care docs.)
But here’s the question: should a doctor who trains for 3 more years be paid six or seven times as much as other doctors, year after year, throughout a 30-year career? At what point has he been fairly compensated for the difference in the years of education? (I don’t have an answer to this question.)
Some would say that being an orthopedic surgeon is more difficult that being a geriatrician or a primary care doctor—that it requires more intelligence and skill. Others would say that treating elderly patients or trying to manage chronic diseases is, in its own way, just as challenging.
The other reason specialists earn so much more is because the RUC committee which adjusts Medicare’s fees every 5 years is made up primary of specialists—and not surprisingly, they consider specialists’ time worth more.
This committee meets behind closed doors and keeps no records of its meeting.. Many people have never heard of it, but it is incredibly powerful. (I have written about the RUC here http://www.healthbeatblog.org/2008/01/who-decides-how.html) The committee usually recommends raising fees, and rarely recommends lowering them — even though, thanks to new technology, some procedures have become easier and less time-consuming.
Medicare usually accepts its recommendations. Private insurers tend to follow Medicare’s fee schedule, though often they pay 5% or 10% more than Medicare.
Finally, when the Medicare fee-for-service schedule was set in the early 1990s, medical services were rated in terms of how much they cost the doctor in terms of: physical effort, mental effort, stress, number of years he needed to train to learn the procedure, number of minutes or hours it takes to perform the procedure . . . ..
Nowhere in the equation is benefit to the patient considered. So a doctor who spends 15 hours counseling a patient, and finally helps him stop smoking is paid far, far less than a doctor who spends 15 hours doing colonoscopies. Fifteen hours of colonoscopies may not save even one life (because most people don’t have colon cancer); persuading the patient to stop smoking may well save his life. But because we don’t count benefit to the patient, that second doctor is poorly paid.
(This is why there are many more heart surgery clinics in this country than there are smoking cessation clinics.)
This could change if Medicare begins to use “comparative effectiveness research” to raise fees for tests and treatments that provide the greatest benefit to patients who fit a particular medical profile, while lowering some fees for procedures that offer little or no benefit to those patients.
Q: Maggie, thanks so much for "MONEY-DRIVEN MEDICINE" film and thanks, Bill, for airing it on the JOURNAL. I am so disgusted with the conservative propaganda machine and likes of the "US Chamber of Commerce" from which I just got a flyer with a picture of a family of sourpusses that is SO distraught over the thought of "government bureaucrats making healthcare decisions". Like insurance company bureacrats are doing such a good job? I did a quick search about this organization and according to what I've found, it is a huge lobby paid for by the pharmaceutical and oil industries. And, judging by what I've seen in the media at the town halls, a lot of (non-informed) people are buying this propaganda. Horrors! Socialized medicine like what Canada and European countries have! Lower costs and longer life expectancy - we can't have that! It's not only the likes of the chamber, but politicians like Senators Grassley and Boehner that have spreading the half-truths. I know that one of the things that make our country great is access to information, but why is there no law against spreading misinformation as these lobbies and sentaors are doing? I am hoping that people who watch Pox (er, I mean Fox) News will watch PBS and your shows and get the real story. Thanks!
- Bruce Juntti
You are right. The people who try to spread fears about “government intervention in health care” ignore the fact that for-profit corporations interfere in the patient-doctor relationship. For instance, every direct-to-consumer drug ad that you see on television is telling a patient that he should tell his doctor: ”I want this product”. Yet the patient isn’t a physician, and short ad in TV is not going to give you the information you need. See this post on the problem and a possible solution: http://www.healthbeatblog.com/2009/08/a-solution-to-the-dtc-advertising-dilemma.html
As for all of the mis-information out there, some people are spreading what Hitler called “Big Lies.” Hitler wrote that if you tell a big lie (such as, “They’re going to pull the plug on Grandma!”), and tell it often enough, people will believe you.
If you tell a small lie, people may question it: “I wonder if that’s really true.”
But if you tell a really big whopper, people think “No one would say that unless it’s really true.” It is especially disturbing when our elected officials tell bald-faced lies.
Q: You would be well advised to stop reading so many books and talk to independant docs who are unrelated to hospital and insurance conglomerates and specialty syndicates.
I agree the AMA has been an obstacle. But aren't you aware, the AMA represents only a minority. They are one hand taking from the industry and on the other pandering to trial lawyers.
Independants docs are not being heard. You will not read this in a book, Sir.
And the most direct evidence of it is Medicare Part D. Fleeced an entire demographic of seniors with the help of the same industry groups, govt economists and legislators. Did anyone go to jail for this . Oh No. The same class is crafting the new reform bill. Wow... another wasted decade is on the way, many thanks to white collar fraud in the healthcare industry
A: First, I agree that Medicare Part D was designed to serve the interests of for-profit insurers and pharmaceutical industries, not to serve the interests of patients. Health care reform is likely to cut back on the windfall payments to insurers, and to fill the “donut hole.” Ideally, traditional Medicare would offer Part D directly rather than farming the program out to for-profit insurers. And under the House bill now under consideration, Medicare would be authorized to use its clout to negotiate with drug-makers for discounts. The Veterans’ Administration already does this very successfully.
As for independent physicians—many of the doctors who appear in the film are independent physicians in private practice. Moreover, when I wrote the book, Money-Driven Medicine, I interviewed a great many physicians in private practice all over the country.
Many were frustrated that our health care system is broken—and that they didn’t have the power to fix it. A great many said something like: “I never thought I would say this . . . “ or “My father was a doctor and he must be rolling in his grave to hear me say this, “ but –I think we need the government to step in and help reform the system.” Only the government has the power to stand up to the corporate lobbyists and represent the public good.
But of course this will take political will and political spine. I am hoping that over the next 3 ½ years the White House and Congress will find that will.
Keep in mind, the legislation we pass this year does not mark the end of the game. Washington doesn’t plan to roll out universal health care until 2013. It will take that long to do it and do it right. Over the next 3 years, as we flesh out the details of reform, the debate will be intense.
Q: I am not sure I heard any nurse practitioners mentioned on the show. It seems to me that more RNs would get the training required to fill the void left by the shortage of primary care physicians. It also seems to me that clinics should be required to post rates for the cost of office visits and other standard care like minor illnesses and monor injuries so folks can get some idea of how costs compare at clinics in their area.
- Just Plain Roy
A: That’s a good point. When I wrote the book I reached out to nurses and nurse practitioners in many ways—on the web, by phone, etc. I wasn’t able to find a single nurse willing to talk to me on the record.
Even some physicians were nervous when talking to me: “Please, please don’t use my name. The politics in this business are such . . .”
And traditionally, nurses have been punished if they broke the silence and talked publicly about what they see in hospitals. Nurses know more about what is going on in our hospitals better than anyone else. There are too many errors, not enough nurses per patient, and too often nurses are multi-tasking. They don’t have the time to provide the patient care that they want to provide.
(I have heard this from doctors)
I agree that many nurse practitioners could provide primary care—or assist doctors proving primary care. Today, the shortage of nurses is caused, in part, by the fact that instructors in nursing schools are paid poorly. As a result, we have a shortage of nursing school teachers, and a long line of well-qualified candidates who would like training to become nurses. The House bill now on the table would raise salaries for nursing school teachers.