As oppose to no help whatsoever, I’d rather have a doctor acting like a whiny brat save my life.

Only $285 for six hours? How do you eat? Dont forget we heavily subsidized your education. Get off your high horse and get to work. Everyone is going to make less money now. Youre lucky enough to have a choice. Because you are a doctor doesnt mean you know a thing about health care reform. Pointless post.

Hey look at me, I make so much money, I can now decide whether I want to save a life or not! SMH… I guess that is the honorable thing to do, based on on the God you pray to; The Almighty Dollar!

Actually, ObamaCare will help physicians, especially primary care and ED physicians get paid for their services. ObamaCare will allow, rather than force, Americans that cannot otherwise afford insurance to acquire insurance at a reasonable rate. And not through Medicare/Medicaid but through major insurance carriers like Blue Cross and United. Physicians would never know how their patients get the insurance; they just know that they are being paid. Also – getting paid by Medicare is not providing charity care – billions of dollars of charity care is provided every year because hospitals cannot deny treatment to patients based on their ability to pay. No, physicians should not work for free; by enabling more if not all patients to pay for the care they receive, physicians would also reap the benefits. This article is a great opportunity to dispel some of the myths of ObamaCare and overall healthcare reform.

You sure know how to stir the pot. After reading your blog I thought, “Is this guy really that provider centric?” So, I reviewed your hospital’s website and found some surprising statistics – well, not so surprising given your business model and the outcomes generally seen when providers are fiscally at-risk when they operate their own facilities and when they need to take quality and consumer-feedback into account to remain viable like other free-market efforts. You’ve been ahead of the curve (i.e. offering transparent pricing on your site since 2009 which is even vanguard today). Your hospital is also very quality focused (i.e. infection rates for 2009 and 2010 as low as .001% compared to the national average of 2.6 % per year). That being said, why not share your business model’s successes rather than creating more consumer & provider chaos? Don’t tell me that you believe that Reform 1.0 could possibly be the final solution? In America the 1.0 version is never the last. We need more minds supporting creative solutions instead of division. And yes, consumer expectations are an issue but didn’t we create that beast in our drive to create the illusion that medicine can cure and that the pt experience should be exceptional? Enough already – join the team and provide positive insights rather than cynicism. I say – share your knowledge of consumer satisfaction as it relates to billing transparency! Now that’s a topic that needs exposure!

You sir are a disgrace to your profession. I suggest you review the Hippocratic Oath, to which you are sworn in order to perform your work. It is NOT all about the money.

This article is a disgrace and disservice to your profession and anyone who would be so unfortunate to receive your services.  You forget to mention the outrageous charges that you and people like you engaged in that are driving medical services out of reach to very large member of our population. This kind of skewed information only perpetuates ignorance to those who do not want to know and research the truth.  Why don’t you to disclose how much you made last year so we can have a context of what you are whining about.

Wow, some of these posters!!  And Obama HASN’T been the president of derision and division?(sarcasm)
 
The decision of a private citizen, physician, to be able to make a living worth the investment of education, hours, years, should be respected in his employment decisions.  As part of the problem: tort reform was not considered in reform because it didn’t benefit the lawyers(Obama) in charge.   I happen to know the huge expense of “malpractice insurance” because “population” takes every “opportunity” to make millions on someone’s mistake.   Come on, would any of these individuals have brought in millions in their entire life?
 
ADVOCATE:   “ObamaCare will allow, rather than force, Americans that cannot otherwise afford insurance to acquire insurance at a reasonable rate. “??
1.  When did they change the word “mandate, penalty, tax” to “allow”?  
2.  Insurance at a reasonable rate?   The exchange will add another layer, you know another middle-man of sorts, to buy the same product that is now offered, only the product will have more demands, regulations, including those with pre-existing conditions – who didn’t bother getting insurance when they were healthy; but now they need care; and want to “balance out the costs” with all the other insured people.  Nice.  Why would the private insurance be sooo much cheaper than it is now?   Will the government somehow show these companies how to be more effiicient or cost effective? while companies have increase their total pay out limits?
 
You haven’t kept up on latest info. – the premiums for private insurance will be higher including higher deductibles.
 
And “rights” come from God.   We have no rights to “take” from someone else, without paying what they believe is the  value of their product.   You and so many leftie liberals are confused and fooled by the legalese spoken by these lawyers, politicians.    Words have real meanings, and if more doctors can’t make enough money from Medicare and Medicaid patients due to lower percentage paid – that will become a problem, getting access to care.

@Rebecca Lefebvre ”Creating that beast, illusion medicine can cure”?
 
As with the entire issue of our government, our current issues; people need to become responsible for becoming educated, be smart consumers, know the costs, with so much information on line and we have such easy access to this information; take the time to get informed.   How many people voted in this last election in favor of PPACA(Obamacare) and have no idea and no intention of finding out what it really is.  They really think it is free or cheap coverage from the government, like maybe Medicare, Medicare????     
 
It’s a huge LAW passed 2010, that increases size, control, spending by our Fed. gov’t over ALL healthcare issues, costs, choices of U.S.citizens, that the majority never even read; and fact, the majority never wanted.  The SC allowed it to continue by simply calling it a tax, instead of a penalty…wow.

@jtrombley How much would a lawyer make for six hours?  And all they do is sue people.

@ettehugh You’re barking up the wrong tree.  How much are you willing to pay the plumber or electrician who come to your home to fix problems?  How much money and time have they invested in their education to learn their trade?  Do you realize that much of the cost of medical care is the cost of “Malpractice Insurance”?  Why are lawyers and politicians allowed to “earn” money for their work, but not doctors?  Why should any doctor who willingly goes to school and usually has invested time, energy, and hundreds of thousands in medical school debt, not be allowed to benefit from the added blessing of their education – and be expected to work for free?  Medicine is not wholly based on a doctor’s salary.  Hospitals need to make a profit to stay in business.  They need to be able to pay for lighting, heating, laundry services, food service employees, nurses, lab technicians, orderlies, clerical people (especially since regulations have tremendously increased the paperwork involved in caring for anyone).  The cost associated with one service at the hospital generally covers a multitude of “invisible services.”  Bandages, blood supplies, equipment (computers are donated free to them either), MRI, CT and X-ray machines cost millions of dollars – they require upgrading almost annually.  Who pays for those things?  No one?  They are all part of the cost of an emergency room visit! 
Prior to “Universal Health Care” we all had the right to seek medical care from the best physicians in the world, having the benefit of the best research and medications in the world.  That will be going away, if research stops being funded and pharmaceutical companies won’t be compensated to do their own research and young people won’t go to medical school to be paid less than a walmart worker.  They are smarter than that.  If you want the best of anything.  You need to pay for it.  You don’t go to the grocery store and pay for hamburger and expect to filet mignon.

@LMsmore  @ettehugh 
How rich do you have to be to have enough? 3 Lexus or 4 Lexus in the driveway. Most doctors are pretty well off. You live in a nice house, You make a nice living, and have established a certain level of comfort in life. But do you sacrifice any more than the local school teacher who buys books for her kids, because the school system, can’t afford to buy them. Is your life more important than the policeman who gets shot at during their career to make life safe for you. What about the soldier who exposes themselves to ied’s? Ok so being a doctor is hard, but that is a choice you made. However, did you become a doctor to achieve a certain income level or to help people. I read a story about a doctor this week who still charges $5 per patient visit. He is having trouble paying his staff but he has been doing this for a long time, and he’s gonna keep doing it because he is trying to help people with his skill. Maybe you and him should sit down and discuss what is really important?

The responses to Dr. Smith’s article prove his point — there actually do exists people in society that believe they have the “right” to force other people to work at gunpoint.

@SeattleNative57
And YOU, sir, missed the point entirely. The oath applies if the good doc chooses to practice his trade, but nowhere does it compel him to do so against his will. So, as a review, exactly where will medical treatment be available if the government price structure is so low as to be a disincentive to practicing as an MD? Or are you implying that the Hippocratic Oath is a contract of bondage and/or that you are entitled to the benefit of someone else’s abilities and labor without fair compensation? Maybe you should focus on reducing those things that result in increasing costs (malpractice lawsuits, folks treating the emergency room like their family doctor, etc) rather than seeking the servitude of those who are qualified to perform that which you are not.

@Gondemar
And YOU sir have made MY point for me. No one holds anything to ones head and forces them into a profession requiring empathy, compassion and skill in order to practice medicine. If you CHOOSE to practice medicine in order to line your pockets maybe you should have chosen Law.

OK folks, I am a nurse of 35 years and I have to agree with this physician. He may be blunt and to the point but he is honest. This is the doctor I would want to see and I would want insurance even if I had to pay for a supplement
( and I do) to see. He is not saying he does not like what he does. Let’s face it 6 hours and $285.( $47.50/hr) there are PA’s that make that amount. If that’s what doctors are going to be paid  after 10 plus years of education, loan repayment, and setup fees plus increases in demand and malpractice costs.  You won’t have anyone going into the profession. This does not even touch the fact that there are sue happy people out there. I had a family member wanting to sue a  CV surgeon because her spouse died after having AAA surgery. Never mind he had stints placed in the past, bypass surgery in the past still smoked, had Polycythemia vera as well as clotting problems. He was a ticking time bomb and she wanted to sue the doctor because he did not make it? This is absurd. Now add to the fact that he would only have made $285. I can see his frustration.
Education, malpractice, continuing education, office, etc. All cost. Why is it that no one goes after the ambulance chasers, AKA the lawyers and  support Tort reform?
My attorney charged me $ 250.00 an hour to draw up my will, and set up POA’S should anything happen to me or my spouse for my children.Why is no one up in arms over this amount?
What do you think the small time docs in rural areas are going to see? Not much. There will be no conglomerate for them to join. They will barely be able to keep light on, Tenn care was an utter failure.
 
Concerning Primary care, many doctors in my area are so overbooked now that you have to wait for quite a while to see your PCP. Many times you are scheduled with a PA.  I have insurance and I wait, so do my children. What are they going to do when they have so many more to care for? They will have to give up some of the autonomy to NP’s. Then you will have the medical profession attacking the nursing profession about this they do not want the NP to have autonomy. They want collaboration. Good luck with that one when they will be so busy they won’t have an option or they will be paid less than this physician was offered. With ICD10 coming down the pike good luck one and all!

Forcing to work at gunpoint? Seriously? This has nothing to do with Obama or ACA. This guy doesnt want to help operate on old and poor people. It doesnt pay well enough. He should just say that and not spin some tail about rights.
My problem is since his education was subsidized by taxpayers and I happen to believe that health care provision is a public good then he should work for the money. Its not slavery. He needs to diversify his patient mix, make more money for some cases than others and do just fine overall.
Why force people to take Medicare and Medicaid? Because if everyone had the choice very few would. Then what?

@ettehugh Are you an MD? 
Or are you one of those that the author was talking about who just demands what you want and all have to comply?

There is post after post making the author’s point about all these people who have decided that the Dr. owes them or something stupid like that. 
Half baked school teachers with 4th rate degrees, other parasites and gimmies stammering about the Dr’s responsibility, etc.      Obamacare is good for doctors, more fair, etc. 
Sickening. 
I guess if we read the post the good Dr. was right in everything he said.  Leeches are everywhere.   They won an election and now we must all serve them. 
The doctor is also right about the fact he doesn’t have to do any of it by his own personal decision. 
Enjoy obamacare.

@Healthadvocate The good Dr. said over and over ,”insurance” is not  physical
health care. Neither you or any other sane person will work as “slave” to the State by being denied
fair compensation. And it’s up to the Doctor – yes to the Doctor – in this “Land of the Free” to determine what is “fair” to him. No State bureaucrat  is in charge his (and your) life.  Unless of
course you fall hook line an sinker for the Obama propaganda and are willing to become the “useful idiot” slave of the State.  Aint gonna happen.

@jtrombley “Just because he’s a Doctor” — he doesn’t know anything about health care reform !!!.  One thing for sure , the local SEIU Union thug is very well versed in “health care”.
That’s why he’ll be in charge !!  I don’t know what you do for a living. But I’m sure it requires of you
lots of “expertise”. So I’m sure you would subordinate  your expertise for my all encompassing knowledge of your business, even though I’ve never spent a day practicing  it. Same logic as your idiotic statement.

@ChristopherNix  So it’s YOU who determines “how much” is “so much”. Well I’m the
Bureaucrat who determines that your efforts aren’t worth sh–. So take a hike.. Big Brother told you to.

Doctors and the AMA have been pushing for the rest of us to pay for socialized medicine for 50 years.  You own it now, baby.  Suck it up and work for peanuts, because that’s all Uncle Sucker is going to pay you.  Next time be careful of what you wish.

It’s absolutely facetious and misleading that you talk about “Obama phones” when no such thing exists.  Factcheck by Forbes of all places: http://www.forbes.com/sites/kellyphillipserb/2012/09/28/crazy-for-obama-phones-but-are-they-for-real/

@jtrombley I’m amazed at all the communist shills showing up on this post, proving the Doctor’s point
NOT ONE of you addresses the fact that lawyers charge hundreds an hour, and that their malpractice suits are the main reason why health care costs have been driven up
but then again, Obama is a lawyer and so are most of his liberal cronies, and they did nothing to address tort reform in this misbegotten aberration of a bill
But your post, sir is scary. You assume we will all make less money (what, because your party is accelerating the decline of ‘evil’ capitalism?), you assume that others must donate their services otherwise they are “whiny” (not that you aren’t, you mental case), and you scold them for not wanting to “help their fellow man”…(since when is charity forced at the point of a gun, or by government mandate, outside of communist countries?)
Furthermore, every communist shill on this blog has assumed the Doctor’s degree was ‘heavily subsidized”….Oh really? Can you provide proof? Most of the doctors I know paid hundreds of thousands of dollars of private money for their education, with almost no help from taxpayers
This is more of that “you didn’t build it” crap that you get as talking points from your community organizer in chief. Sorry to burst your bubble, but medical degrees aren’t paid for by communist front groups, like your worthless degree in social engineering or ‘communications’
You people are abhorrent. I know now that there truly are marxists among us, because this is the first thing all marxist and communist revolutionaries do: go after the medical profession, I have no idea why
it must be sheer envy

@SeattleNative57 You prove why I hate Seattle and glad to live in Texas. So, you’re going to hold the hippocratic oath over the medical profession as a way to force them to donate their services?

@ettehugh What, did HufPo send over all the marxists in training to scold that Doctor for his honest and correct views, by calling him a “disgrace”?
LMFAO, you guys are so obvious.
And what the hell is wrong with expecting to be well compensated for a job which takes 1) high intelligence 2) unusual aptitude and skill 3) tremendous focus and concentration requiring years to acquire the degree and finally 4) willingness and ability to spend hundreds of thousands of dollars to acquire the education, money which the taxpayers DID NOT subsidize, you ignorant fool
Someone had to pay for that education, either the parents or the student themselves. So, are you saying it is the state’s right to force parents to donate a doctor for the ‘greater good’?
You are a marxist. Let’s just get that straight. You think money is vaguely evil and wrong, and you do feel you have the right to someone else’s labor, and if they refuse, then you pull out the old “you’re not a nice person, because you refuse to help your fellow man” card…(but refuse to asnsewr the question of why lawyers somehow are not held to the same charitable standard, lol)

@jtrombley why does he “need” to do anything to please you or any government agency?
It wasn’t long ago that there was no medicare or medicaid, and as citizens of the US we have no ‘right’ to such services. They are no where in the constitution, nor in the charter of the country.
If you want a country where people are “forced to take medicare and medicaid” patients, I suggest you move elsewhere, because what you want is a communist government where people’s labor is seized for a supposed greater good
A society where people have the choice to refuse to be paid less than you wish to pay them scares you, and you ask “then what..?”
Unbelievable
I’ll tell you “then what….”. What you will get soon enough is a shortage of doctors and services because the ones who can will retire, and you will not get new people applying to medical school in the same numbers. These are smart kids and they will choose to do something else. I know, because I’m married to one.
I’ll tell you what you get: you get Canada, where there is a 10 year wait for a family doctor, and 15-30 waits in the ER for any ailment at all
idiot

“I increasingly saw myself as the recipient of money taken from my neighbors against their will.”
 
Yeah, doc… and when your house catches fire, put it out yourself with a garden hose. If you let the municipal firefighters do it, who are paid through tax revenues, you’d be receiving services from people who are “recipients of money taken from your neighbors against their will.” If you’re being mugged, fight back — but don’t call the police; they’re paid through tax dollars as well. Both firefighters and police put way more on the line than you do every day of their lives, and they’d be thrilled to receive $285 for a six-hour shift.

@ettehugh What do you do for a living? I want the ‘right’ to have what you do FREE!

@Calamity Sane You make some very good points, and there is no doubt many inequities in healthcare, (as in all of life) I also work in health care as a chaplain, and while there may be some validity that a physician should not be “forced” to work on people for whom they feel their work is not reimbursed at what they believe it to be valued, I also believe that those seeking, and in need of treatment, who perhaps fixed cars or picked up trash, (worked as health aid, MSW, or chaplain) and are now on medicare, deserve to be treated. And, I agree with Dr Smith that they should be treated by a physician who wants to be there and sees them as valuable.
 
Having worked with many physicians in my life, I have been privileged to work with many who are both passionate about their work, and compassionate toward those to whom they provide care. Unfortunately, I have also seen much greater numbers who seem to be in the field as simply a way to make the greatest financial remuneration for their time. Okay, that’s fair,  we see attorneys, business owners,  CEOs, professional athletes, and people in almost every line of work, including mine for whom that is true. As we are reminded regularly, we live in a capitalistic society. But I’d like to believe we also live in a society where we value people more than the almighty dollar. 
 
While I recognize the importance and value of physicians to our society, as well as the value and importance of good CEOs, and business owners, I prefer to have people in all those positions who hold a high value on all human life. Yes, physicians deserve to be well paid for their training, knowledge, wisdom, skills, and the risks they take in holding the life of another in their hands in delicate surgical procedures and diagnosing and treating various illnesses. Perhaps when all people are having to invest in health-care, and the costs are more fairly distributed and services are offered to all before they become critical, this will improve. ( I recognize this is not widely accepted among many in the healthcare field) 
 
One thing few can argue with is, healthcare costs have been out of control and have to be better contained if our society is to survive.  I hope we can maintain the dialogue, and find enough people with the wisdom and compassion to find good answers.

As a physician, I find this post bith saddening and blankety untrue. Most of us are drawn to our profession out of a sense of duty to the broader community, not out of a desire to make money. Yes, it is true that through our schooling many of us accrue $200,000 in debt, and that for the first six or so years out of school, as sub specialists go through year after year of training, they often work 80-100 hours a week for under $60,000-$70,000 a year–a far cry from our lawyer or banker counterparts, and that the rise after training, for the vast majority of is, comes nowhere close to those professions. But that is, I should hope, not why most of us went into the field. Medicine is no longer lucrative. But it is a great way to make a difference. And society will be much better off if we do our part in helping others. And, the little secret that people seem to forget is that hospitals cannot legally turn people away in crisis. So, by denying basic care to people without insurance, studies have repeatedly shown that we actually increase the costs to hospitals and taxpayers. Because, really, when your grandmother walks in dying from a massive heart attack, do you want us to check her insurance card before we save her life?

As a physician, I find this post both saddening and blankety untrue. Most of us are drawn to our profession out of a sense of duty to the broader community, not out of a desire to make money. Yes, it is true that through our schooling many of us accrue $200,000 in debt, and that for the first six or so years out of school, as sub specialists go through year after year of training, they often work 80-100 hours a week for under $60,000-$70,000 a year–a far cry from our lawyer or banker counterparts, and that the rise after training, for the vast majority of is, comes nowhere close to those professions. But that is, I should hope, not why most of us went into the field. Medicine is no longer lucrative. But it is a great way to make a difference. And society will be much better off if we do our part in helping others. And, the little secret that people seem to forget is that hospitals cannot legally turn people away in crisis. So, by denying basic care to people without insurance, studies have repeatedly shown that we actually increase the costs to hospitals and taxpayers. Because, really, when your grandmother walks in dying from a massive heart attack, do you want us to check her insurance card before we save her life?

With the ObamaCare, it will weed out the “Bad” doctors, the ones who got into medicine for the money not because they truly care to care and treat people.  Healthcare SHOULD NOT BE FOR PROFIT!!.  This articles justifies that here in America, there are lot of doctors that go into medicine to be come millionaires. They just think of making money from the sick.  Sad state of affairs.

Some of the things Dr. Smith discusses are not in the ACA.   I am on Medicare, having chosen the option of a replacement plan that allows me annual labs and little else, and I pay a co-pay to see a specialist just to talk.  Under Medicare alone, it seemed I would be paying more for care.   I agree doctors should be paid for their services, however, health care providers should not be charging $20 for a band-aid.   The last large corporation I worked for in 2003 charged me for benefits and it was less than $150 a month.  Before that, as an independent contractor, I paid $150 a month for health insurance in 1998, and when the premium rose to $250 a month in 1999, I opted out of health insurance.   Under the Medicare replacement plan, I pay about $200 a month and shipping on drugs.  I doubt the labs and the drugs cost $2400, so I presume the difference goes to the insurance provider, who decides whether to pay the medical provider or not.  It surprises me that a doctor would use his credential to lend weight to his opinions that have no basis in fact.

As a healthcare professional, I have grown dismayed over the last 43 years as I watched the growth in numbers of people like you who are just “money mechanics”,  going through their daily routine, hearing “cha-ching” every time they walk in a patient’s room and flash that smug smile.  Patients would be shocked if they could see inside your heart.  Just hollow emptiness!  I’ve worked with many MDs like you as they objectify patients and hold out their hand to be paid while they couldn’t care less about the patient in front of them.  I’m sure you follow the practices/procedures you learned in your medical education just to be on the safe side…wouldn’t want to get sued. It’s not about the patient or finding happiness in life unless you call amassing more and more money happiness.  The next surgery I have, I hope you aren’t anywhere near me or mine.

at $285 per 6 hour surgury, he can only make $416,000/year practicing 24 hours a day, 365 days a year.  Now he likely has 10 years post high school education (4 college, 3 med school, 3 sub-specialty) with a $400,000 investment in that education.  I don’t think he’s saying ” I have to be a millionaire”, but he should be looking for a reasonable return off 10 years of hard schooling and a $400,000 education investment.

@SeattleNative57  @Gondemar SeattleNative57, where are you going to go for surgery when every anesthesiologist follows your advice?

he’s talking $48/hr for supporting a surgury he could likely get sued on a bad outcome.  You pay your pluimber more than that and unlikely you would sue over a bad outcome. People don’t die if the plumber didn’t fix the clog the first time.

I’d be interested to know over the course of his career, how many millions of dollars he’s received from Medicare…either through direct payment or as part of his surgery center profits.  My guess is that he has been rewarded handsomely for his efforts.  
 
I’m glad that our teachers and police officers do no have the same attitude as the author.  I’ve been shocked throughout my career at the number of docs that put $$ at the forefront of decision making.
 
And please include me as one that is disappointed that medcity would publish this selfish and divisive article.  But seeing how he’s from Oklahoma may explain the hatred in his heart for 47% of the country.

@socratesdog you’re so right. There are others out here who feel the same way. You know, it helps to remember that those individuals that go to work and never actually experience helping a fellow human out, will never get it. Money is not the only blessing. Growth comes from freedom to choose. Health cannot be mandated. Quality of life comes largely from our environment which to some degree is determined by our government, but is mostly determined by choices. I think we can all agree that socially speaking, it is tough to be an American, but I am not going to ever see Obamacare as the solution to our problem.

Well, you’ve just made a good argument for  the ACA. If it drives out a few of the wholly self-centered financial opportunists, good riddance. The audacity to declare that your level of interest in the patient’s care is only related to the hourly rate you get is more frightening than your actual threat of telling it to aptients and their families in pre-op. The Oklahoma state medical society should investigate your comments and care to protect the rest the fine, hard-working and caring medical professionals in the state.
 What good is it for a man to gain the whole world, yet forfeit his soul?

@ettehugh 
You have no idea what you are talking about. Physician compensation accounts for 10 cents of every health care dollar spent. That is fact. Do the math and understand that insurance companies, lawyers, and big pharm make the lion’s share of profits in the industry…not physicians. So I would say that it is you dear sir who is the disgrace and an embarrassment due to your ignorance and myopic view. If you are a physician and wish to work for nothing, join the Peace corps! If you are not a physician, please continue to feel free to hold onto your uneducated viewpoint. Opinions are like a**holes indeed

@JJS You don’t think that the workers are worth their wages? Should restaurants give away their food instead of charging for it because everyone has a right to eat food? Or gas stations give away gas because we all must surely have a right to fuel our transportation needs? Who should be footing these bills if not the consumer utilizing the products and services? If the consumer doesn’t want to pay the bills, then they should learn how to acquire the necessary means themselves, right? Grow and prepare their own food, drill and refine their own oil, learn and practice medicine as they need it. the andwer is not to force others to give them what they want. That sounds more like robbery, doesn’t it? The sad state of affairs is the increasing lack of drive to work for a living in this nation. The opportunities for success are available, but it actually takes effort to achieve them.

Is there something preventing one from charging more than what medicare gives? You say they give you 285$ Why don’t you just charge 385$? You’ve just bumped your rate up 20$ an hour.
 
P.s. I know of at least 2 doctors who are very happy with Obamacare. Not all doctors feel like you.

Is anyone considering the amount of money physicians must invest to receive those credentials?  Put the ‘how much per hour’ aside and consider the comparison to the teachers of America who have a vital role in shaping our future and how they have to survive on very low incomes. Do we want to do this to doctors as well? Too often we forget what goes into the making of a great physician – not only do they invest money but they sacrifice family time, social lifestyles, and an eight hours night of rest (in some cases) to serve their community. I know that I believe that is something that deserves recognition.
 
If that’s not enough, let’s consider other jobs with sufficient salaries. We have no problem paying executives of oil & gas and electronic companies hundreds of thousands of dollars but we want to force our doctors to give us treatment that has taken them years to master and have the credentials to provide. This does not even touch on the topic of the many people who want to sue doctors because they caused the death of their family member(s). Or just think of the entertainers you pay millions of dollars. They turn around and buy too many cars and houses, but there are no complaints to that regard, are there? Today’s society follows whatever the mass population is saying – even when they have no idea what it truly means. That is what is really sad.

Meanwhile here in Canada where we have had a single-payer system forever (which is admittedly much more sane than your proposal)  a poll this week found that:
 
“Universal health care was almost universally loved, with 94 per cent calling it an important source of collective pride – including 74 per cent who called it “very important.”"
 
Source: http://www.calgaryherald.com/life/Poll+points+lagging+support+monarchy+among+Canadians/7609255/story.html#ixzz2DMESUM7p

@JJS how many times have u paid a doctor. They are usually paid by insurance companies or by medicare or medicaid on a pre decided amount Please tell me one Doctor that’s a millionaire.

@ChristopherNix  @ettehugh 
By the way, I’m not a doctor.  Lots of people live in nice houses and drive lexus cars.  I happen to know a lot of doctors – and a large percentage of them live in average sized homes and drive normal or old cars.  Many of them don’t take fancy vacations, and a lot of them give free medical care/advice to family, friends and neighbors.  A great number of doctors actually donate their time to Medical “Missions” in third world countries and many do surgery for free for special cases.  I don’t know any doctors who went into medicine to get rich.  I do know many doctors who work call shifts of 24 hour days for a week at a time.  12-13 weeks a year.  What job in the United States will require that brutal of a schedule and not pay for it?  To expect doctors to work for free (free medical care is going to cost someone!  If not the patient – certainly not the government – then it WILL cost the doctor).   There is a large population of people who make too much on welfare to even think working at all is a viable option.  If they won’t work for minimium wage?  Why should doctors work for free?  I also know a doctor who has been laid off, because he is the younger doctor in a hospital who can no longer afford to staff 3 surgeons.  The two older docs are almost retirement age and won’t be able to keep up with the load, but the increase in cost to the medical center (due to “Affordable Health Care Act” aka Obamacare – means they have to cut services.)

@SeattleNative57  @Gondemar 
The majority of doctors do not line their pockets… they pay huge taxes and try to pay off $150k to $200k medical school debt.  Do you have a home mortgage?  Do you know how interest works?  How long would it take you to pay off that debt (which is like having a really nice second house)?  30 years?  Why shouldn’t doctor’s be paid enough to afford to have a family, a home, and pay off their debt, without being vilified?  Are there doctors who live like kings?  Sure.  Are there basketball players, movie stars, singers, football players, CEOs, lawyers and politicians, etc. who live disgustingly extravagant lives (way more than most doctors!)  Most doctors I know don’t live like kings with multiple castles and servants.  Most doctors live in middle class homes, driving middle class cars.  Look around with your eyes open!  But no one screams about how ridiculously expensive it is to go to a Superbowl game or playoff game of any sport.  Even those who are supposedly dirt poor, still afford big screen tvs and iphones?  But they scream about having to pay a doctor?

@otakurelix My insurance company has dictated to dr.’s, dentist and hospitals for years on how much they will pay. If they are satisfied with that, I received a bill. If they were, life went on! I don’t see anything different now, so why wasn’t everyone screaming at the insurance companies for setting the rates!

Medicare tells docs and other providers what it will pay.  Charges have nothing to do with how much they pay – he could charge $1,000,000 and Medicare would pay $285.

I’m so glad that im working in the technical field and I cant wait to continue to invent devices to get rid of doctors like you, we already started removing your hands out of the operation room and without us you guys wouldnt even make a dime now, because we invent most of the devices that you people use(your welcome) and yeah you didnt pay us much for it and we’re not asking for your money, Im hoping we invent something so a  doctor in India that gets paid $10/h can do your operation much better than you and call this “free market”. The only reason why you get paid unheard of amounts of money by taxpayers like me is because people get sick and have to go to the ER room and pay 100x more. Im sorry you get paid $50 an hour, I have way more years of study than you do and I dont complain I’m not making $1000 and hour, is about time you people get paid fairly. How do you think I like it when after my 100′s of thousands of education, masters, and phd are replaced by someone in China making 10 cents an hour? I would love I could charge you $1000 every time your devices that keep your patients alive way better than you do have to get fixed, these devices are allowing you to charge $250/hr for a patient that spends 15 minutes in your office, what logic does that follow ? only reason why doctors are expensive is because the’re not enought normal physicians because you guys prefer to do a specialization and make 20x more, so once that lowers which is the point of HC, you wouldnt do that unless you like what you do. Welcome to the Globalization  era, and thank your republicans and democrat friends.btw stop being so racist and classist, not everyone is born with a silver spoon that can afford medical school.

@RALoh yeah so im not a doctor but i have more than 10 years of education which is worth more than $400K so should i get paid as much as he does ? sure maybe but i dont hear you complaining about your cheap Iphone, yeah iphone should cost you $10000 if it was made in the US by people with actual degrees

@Anesdoc  @JJS
pretty much every doctor i know has more than 1 million dollars in his/her account. Besides you miss the point on HCR, the idea is to lower the cost for ALL taxpayers, so instead of us paying ridiculous costs, it would be the insurance companies paying these costs, read the legislation i can guarantee that non one here has read any of them, they have no clue how is going to be implemented and instead complain about it because it came from a black man,

@Calamity Sane
you need to read the law before making all the assumptions this person did. First of all the government is NOT going to pay for the services, so its not like everyone will have medic aid, instead its the insurance companies that would pay these services so he would get more money and you too which is unfair because i can find more than a million doctors and nurses that are waaaaay better than you people in India China, and the rest of the world that would perform these surgeries with at least 1/3 of the cost, they cannot do so for stupid laws , thats why your field hasnt been affected by the “globalization” fiasco.
I spent 10 years studying for technology and I paid a lot of money for that, a lot to get my ph,d and career so does that mean i should get paid $1000/hr ? i wish, so just be glad your era is ending and people can get better  health care, at least us ,te technhology people we are #1 in the world, so when y0ou guys in the health care get at least in the top 10 in the world, just then i’ll accept your complains, for now, your services are bad and ranked #33 in the world, thats a shame, doesnt seem like those 10 years are worth it and you should be paid accordingly

Yes, there is a maximum you can charge Medicare patients. If you are a participating provider you have to accept their allowable. If you are non-participating, you can charge more, but there is still a limit to how much more….and Medicare will pay the subscriber, not you, so you will also have to collect it from the patient.
 
That said, the vast majority of physicians are Medicare participating providers, and are happy to have their Medicare patients. They know they will get paid….even if it is less than they charge other patients. Also, almost all health care plans have limits to how much a doctor can bill the member if the doctor is a participant…and if the doctor is not a participant, the patient will see someone else.
 
Also, where is it written that a doctor has to drive a $100,000.00 car?
 
I believe this doctor is in the minority who are only in medicine for the money. Frankly his attitude sucks.

@RobertX Exactly…couldn’t have said it better myself

Dr. Smith’s main point (as it seems to me) has to do with whether health care really qualifies as a “right” the way so many people claim.  Those in favor say it is a right because we all need it at some time.
 
Food and housing also qualify as rights by this standard.  If you have a right to food, what prohibits you from filling up your cart at the supermarket and walking out the door without paying?  Should it be against the law to exercise your right to a house by deciding to move in with a homeowner without her consent?  If we have inherent rights to food and housing, don’t laws about stealing and personal property directly contradict those rights?  Or does demanding that somebody else pay for my food and housing violate the rights of those I think ought to pay?
 
Medical care does not seem drastically different from food and housing in this respect.  We might like to talk about them as “rights,” but we don’t behave that way when it comes down to it.  Legitimate rights do not violate the rights of others.  If something requires the labor or money of another, it does not qualify as a right, even when everybody needs it at some time.

@hello_dude  @Anesdoc Yes, and we mandate the insurance industry to pay all sorts of services, because as a society we really do believe people should be able to have, for example, pap smears, PSA tests, mammograms, cancer treatment, etc. What we don’t agree on is who should pay for it. Our laws mandate the insurance companies to pay for it, but that just means they’ll raise the premiums…and soon no one will be able to afford insurance…and of course, the insurance companies, whether Medicare, or for profit carriers, tell the doctors how much they will pay. 
In the end, the method that works best, is where society shares the expense. Unfortunately the ACA was largly made to make the insurance companies happy, and in the end it will not solve any problems.
No one is saying doctors should not be able to make enough to pay for their education, and make a decent living. That is what happens in other countries, and the cost is hugely less per capita.
The argument to that is then: “Yes, but we have the best medical care in the world” Unfortunately, that is only true if you can afford to pay for it, and anyway, how exactly do we define: “The best medical care in the world.”  Personally I don’t believe that being 34th in the world in terms of infant mortality indicates we have the best medical care in the world. It means we have the 34th best medical care, and if we can do better by distributing the cost to everyone, I am all for it.

@Walter Mitty
 What about all those stories I hear about cancer patients who have to wait for care and end up dying?  There have been several stories from Canadian patients who either died due to failure to diagnose or treat, or finally crossed the border and came to the US for care out of desperation.  They didn’t seem as enamored of your system.

To the first part of your post..exactly…but the point is THIS doctor is not one of those doctors you are describing.
No one, I repeat no one, is asking doctors to work for nothing.
Also, please give me the name of one person, much less a ‘large population of

@Walter Mitty Really?  That’s why so many Canadian’s come to America for their so called elective surgery because they wait and wait. You also do not have the amount of people we have , in population numbers AND what is your work to welfare, disability, illegal, low life ratio??? HUMM?
 No where near ours.

Teachers have a low income?  Try nurses. Very few weekends off holidays off shift work . Still treated like piece workers, and handmaidens. No summers off that’s for sure.
I blame unions for teachers problems. They just take and take and they shore up bad teachers as well.
Docs do not have unions.Then they get blasted like this guy. Very few NP’s and PA have unions as well. But sued you bet ya!, Malpractice costs of course. Many with call hours. Yes we chose our profession and so did teachers.
We did not choose Obama care. It was ramrodded down our throats.
It is going to come to the point of survival of the fit. Those that can pay will and those that cannot will have Obamacare God help them when they are really sick.

Yes it is called coding, billing and the maximum payout  allowed by medicare/medicaid.
There is a physical for children that are on Medicare that is completed annually. Children covered by regular insurance with their parents do not have this elaborate Physical. It is called an EPSDT> The PE is crazy in what is expected. It takes more than 45 – 60minutes to complete and all the doc can charge is a level 4 for medicare. It does not pay very much. This ties up three or four visits. What the docs usually does is punts half of the testing to his nurses ans still it takes time for a whopping $75.00. By the time he pays the billing clerk, the nurse, the injection fees( because it also includes immunizations, a Denver developmental test for younger children. It is plain not worth it. To top it off they are to be conducted until the child is 21. Not 18! Never mind if they have kids of their own. They are still entitled if they have the gold card!

Where did it say he drove a 100,00 dollar car? If he has children I am sure he has family care just like everyone else and LOANS for his education that people benefit from No one is bugging about the lawyers charging out the wazoo are they?
 How about some tort reform so this guy does not have to worry about multi-million dollar  frivolous  law suits?

@Calamity Sane
In your post you speak negatively of PAs yet turn around and speak of NPs needing autonomy……why do you feel on profession is superior to the other when they both require the same amount of schooling and professional liability once in practice?

I hope those two docs can cover 50 million!

@Chaplain Craig Chaplain None of this would have gotten out of hand if both sides : A) would have done a Research study on both the Republican plan and ACA plan small scale in a few states for a period of two years. They could of implemented this in CA and NY the last two years for the ACA and say Texas and  Florida for the Republican plan. See what plan was more viable. The gradually allow states to select what plan worked best for their constituents  via a vote.
CUT THE FRAUD, the waste, and PUT IN TORT reform in those research states and watch what would happen.  In the republican states also add insurance rate freeze( this should have happened 4 years ago, but neither side did a darn thing about this problem. Bet there would be lower malpractice, lower costs for all and more overall coverage, because the insurance big wigs could not gouge!

Disclaimer: I am a Doctor from India who chose not to practice and became an investor and entrepreneur.
 
Well there have been many arguments in favor of the author and even more against him.
 
If anyone here is hoping to get any good care, create a very good incentive for someone smart to enter the medical profession and dedicate his life to it or else what you will get are mediocre doctors in plenty who can hardly diagnose or treat.
 
Socialized medicine looks fantastic and sounds ideal but will not deliver. The minute you start squeezing doctors, the smart people will go else where (there are plenty of other opportunities out there) and when smart people opt out, quality of care will fall. A system cannot deliver good care, only people can. I have heard many from other parts of the world where they have free health care but what use will that be when the doctor you see is not good enough to diagnose your problem and treat your illness. On the contrary, If you retain the standards and still squeeze the profession, there will be severe shortage of doctors. (Some parts of Europe)
 
Someone even pointed out to doctors in India treating for peanuts. Yes there are doctors here one for a dime, but if you wanna see a good doctor it will cost you dear. My father is a doctor in India and he makes as much as any other doctor in the USA.
 
Just passion wont help, incentive too is required to keep the people in.
 
Has anyone thought about putting a cap on Health Insurance Company profits to say 20% of revenue? Squeezing a financial company to go thin is better than squeezing a hospital! Why not simplify insurance and create just three plans (hypothetical number) or even just one plan and let insurance companies compete to bring the costs down. It will make a lot of difference.
 
Teachers and police should be paid better and an argument in favor of these underpaid professions is much better than one to bring doctors also into this league of underpaid workers.
 
Walkaway from social health care before its too late.

It sounds like your real problem is Medicare and probably Medicaid. Perhaps you should write your congressmen and women and tell them to dissolve those two programs. Obama care, on the other hand, does not suggest you will make less than costs on patients that are now covered by affordable insurance.

@Healthcare professional
Regarding compensation of executives, ‘we’ do have problems with it. Is has spiraled out of proportion to the work they do, especially the golden parachutes given after disastrous outcomes that ruin shareholders. MDs should make a lot of money. The problem is that wages have not kept up with costs of living over the last several decades and the ACA is a result of that. It’s hard to put this all together without an economic and historical perspective.

@RAL I agree.  And would you expect to get good care if a doctor were truly practicing 24 hours a day, 365 days a year?  Even doctors need to sleep and hopefully have some family life.  One 6 hour surgery a day would be pretty draining – they aren’t allowed to scrub out during surgery!  No eating, no drinking, no toilet breaks.  Would you want to be the second patient of the day after a 6 hour surgery?  Not all doctors are surgeons either.  The funny thing is… the medical bill doesn’t all go to the doctor!  Hospitals have to pay a large staff to run a facility: nurses, ER technicians, secretaries, receptionists, maintenance staff, laundry services, paper products, drugs, computers,etc.  Doesn’t anyone work for a business and understand how the sale of a product pays for electricity, heating, phone service, etc.   I don’t think the nurses, techs, or any of the other hospital staff will work for free either!  As a matter of fact, I don’t think the bagger or cashier at the grocery store, the farmer who brings in the produce, the trucker who drives food to the store or anyone else at whatever job they do will continue to do it for free.  All basic needs are not basic rights.  Everyone still expect to pay for groceries, gas, clothing, homes?  These are basic needs, but aren’t free – nor should they be.  The cost of gas is increasing the cost of all these things.  Bad policies in Washington, are increasing the cost of living.  Regardless, doctor’s don’t get free education to become doctors – so why are they being vilified for expecting to be paid at a rate commensurate with their education.  Politicians and lawyers should have their salaries unilaterally slashed first – that would decrease the cost of business by much more than medicine.  And I’m not even a doctor although i have studied economics.

Dear @praveenbm5,
These are great points that you make. However, it is the economic developments in the U.S. that have lowered wages amid rising costs over the last several decades are the main problem here. Middle class people like me and my family are earning dollars that buy way less than they did 30 years ago. And we (especially those of us who are the first generation to go to college) are way more educated than out parents. The fact that MDs (most of whom were ushered into their careers by their already wealthy families) are now feeling the squeeze speaks to the severity of the problems created by decades of slanted economic policies here in the States.

Dear @Lahchcc,
People in our country work way more now for less money than ever before.

@jtrombley Doctors do not have tax subsidized education!  That is pure fallacy.  The only ones who do are those who are in the system to “balance” the minority share of the school.  Unfortunately those who don’t make it in with their grades, don’t always make it through the system.  More and more medical students are coming in from overseas (THEY get the cost breaks / or their country of origin pays them to go to US schools).  Many of the foreign medical students choose not to go back to their lives in their home countries either. 
 
$47.5 per hour?  That’s less than $100,000.00 per year!  How does a doctor pay off their $200k + interest medical school debt with that?
 
I’m not a doctor, I do know several though.  And just because you can use a computer to type doesn’t mean you know anything about health care reform either!  Whatever your occupation, let’s just say your boss decides that come January 1, 2013 your salary will be cut a minimum of 21%!  Will you still be able to pay your bills?  “Affordable Health Care” is expected to cut payments to hospital by something like 30-40% on January 1st and additionally cut doctor’s salaries by 21%.  A lot of people besides doctors work at hospitals.  There are going to be layoffs, there will be a decrease in care.  It is coming – it’s what has been voted for.   And it’s ignorant to think that someone who spends their life to become a doctor would ever be able to make enough money to pay for the loss of those extra 10 or more years of education, the loss of 10 years of vacations, maybe the sacrifice of family – to call those who sacrifice so much to care for you greedy.  Choose your doctor wisely.  If you act like he’s not worth the money he makes, he’d be justified in telling you to find someone else to treat you.  If you think he’s not worth the money, go to medical school yourself!

No, David… the firefighter who rushes to put out the fire in YOUR house is paid with MY tax dollars.

PERSPECTIVE IS EVERYTHING!!!
 
I’m a primary care doctor who works in the hospital and office (and yes I treat Medicare patients. Also I’ve cared for patients lacking insurance and have never received a dime for treating those patients).
 
EDUCATION COSTS:
1. 4 years college.
2. 4 years med school ($50,000/yr fully out of pocket, not having received any taxpayer subsidies).
3. 4 years residency (working 80hr weeks at roughly $10/hr).  For many specialists, residency is 5-7 yrs.  Some go on further to do 1-3 year fellowships. 
4. $300,000 debt after finishing medical school.
5. Weigh the opportunity cost of this education (my computer programming/engineering friends in Silicon Valley having been making $50/hr for the last 12 years in which I’ve paid $300k for my further schooling).
6. Studying 4-6 hrs/d for many exams, including paying to take (and attend Kaplan review courses for) the USMLE Step 1, 2, and 3.
 
MY OFFICE EXPENSES:
1. $8000 rent/mo (roughly $100,000/yr).
2. 3 office employees (roughly $150,000/yr for receptionist, medical assistant, and medical biller, including their health insurance, social security, 401k, disability, and other benefits).
3. EHR ($40,000 for 1st year, then monthly for IT/customer support).
4. Miscellaneous (e.g. office supplies, office furniture, office utilities, multiple phone/fax lines, multiple computers, medical equipment, injectable medications, my licensing/credentialing/malpractice fees, etc.).
5. Annual overhead expenses roughly $300,000.
6. Making $285 over 6 hours ($47.5/hr) is nice but won’t allow me to even break even with the office expenses.  That is why many doctors don’t accept Medicaid (and possibly soon to be Medicare) patients, because for each patient you see, you lose money. Obama has promised to cut Medicare reimbursement to hospitals and physicians even further, which will likely close many doctors’ offices and clinics.  Medicine is a business like any other.  There are rich and poor doctors, just as there are rich and poor artists, musicians, business owners, or any other profession.
7. Doctors’ visits are expensive because of the litiginous environment that exists in the US.  When I treated patients in rural villages in India, you don’t have to charge as much because the overhead is less (OK, I treated them all for free, after the 2005 Tsunami). The good things is that I had no worry of being sued by these villagers. The bad thing is their poor access to medical care, as many hadn’t seen doctors in years, and would never be able to get to a cardiac cath within the 1 hour standard for treating ST-elevated heart attacks. 
 
“RIGHT” TO HEALTHCARE?:
1. Currently fire/police are public goods funded by taxpayers.  Until there is a National Healthcare System, like in Canada or the UK, it is not a public good.  That is why there exists free county hospitals and systems like Kaiser (where you have to pay a premium), and everything in between. Similarly, in post high school education systems in Calif, there are city/community colleges, state colleges, UC’s (like UC Berkeley), and private universities (like Stanford). In contrast, there are no tiers for fire/police systems (there are no such thing as private and public fire and police stations).
2. National Healthcare is great in that it provides access to virtually everyone but promotes mediocrity. For example, many Canadians cross the border as they would have to wait 6 months for an Abdominal CAT scan, or 2 years for a hip replacement surgery. The medication Zyvox costs $1000/d and is used to treat VRE, a highly resistant bacteria.  It could prove difficult to routinely get this medication or expense cancer chemotherapy meds for free in China, India, etc. I think that many Americans take for granted the access to cutting edge medical technology and resources in this country, yet they claim it as their “right”, and are asking to have it for free/cheap. 
3. But as the expression goes: You can’t have your cake and eat it too. You can cut medical spending and then your access to these services decreases, or you can increase spending and then increase the national debt (or pass the debt along to consumers by increasing taxes or raising insurance premiums).  That’s right, don’t expect greedy insurance companies to want to pay for more people who originally couldn’t afford insurance prior to Obamacare, without first increasing the premiums on those who can afford it (yes that may be YOU!).  Why do we expect doctors to work at a discounted rate to care for patients but we don’t have any such demands on these insurance companies.  Why is it ok for insurance companies that they only care about the money?  This is a double standard.
4. Should doctors work for free because they are providing “Compassionate Care”?  Would you perform your job for free or receive the pay that workers receive in China or Mexico? I’m assuming you are saying “No.” Then why should doctors be required to do so? That is another double standard. You can’t say you want your American doctors to be paid as they are in Communist China, but want to be able to have the ready access to technology in Democratic America.  That’s another example of trying to have your cake and eat it too.
 
SALARY COMPARISONS:
1. My guitar teacher: $40/hr
2. Physical therapist: $45/hr at Kaiser Northern Calif
3. Pharmacist: $55/hr
4. Acupuncturist: $65/hr
5. Chinese herbal medicine “doctor” in Bay Area: $60/hr
6. Chiropractor in San Francisco: $85/hr
7. My computer/engineering buddies average $70-120k/yr, since graduating college at 22 yrs old.
8. My dentist charged me $200 for 15 minutes of face time
9. NFL referee: $200k, up from $150k
10. Investment Bankers: $150-300k+
11. Senior architect engineer: $200/hr
12. My malpractice attorney: $310/hr (haven’t been sued yet, thankfully)
13. Mitt Romney: $42mill in 2010 and 2011 (paying a 14% tax rate)
14. Alex Rodriguez: $29mill ($275mill over 10 yrs), not including endorsements
15. Justin Bieber: $55mill ($300,000 per show)
16. Oprah: $290mill
 
People were upset about Dr. Smith complaining about making $285 over 6 hours. Get a grip people!!!
 
PERSPECTIVE IS EVERYTHING!!!

Devices can only do as much as they are instructed to do. End of the day we need a doctor to understand and use these devices. And believe me they have extended the reach of modern medicine but haven’t made the physicians life any easier.

I usually do not make any posts, but after reading this article I could not hold back.  This article is very misleading and providing a very ignorant point of view.  Our healthcare system is broken and having people continue to think like the article above will not help us fix it.  One of the main ideas of requiring peole to have insurance is to spread the risks of costs.  The ACOs are not there not to provide care – that is a very ignorant statement.  If you look at the research, in the US we actually spend more on healthcare than any other country and the outcomes on average are worse compared to other developed nations.  There is a lot of waste in the system and Obamacare is trying to get rid of some of that waste and at the same time improve the overall outcome of healthcare in the US.

@Walter Mitty
As a Canadian physician I can tell you that for acute care this is true. As for the other comments it’s funny how we talk about evidence in medicine and yet many in favour of the US system are happy to quote the anecdotal cases from Canada getting care in the US as representative. That’s like me saying everyone in the US goes bankrupt when they get healthcare. Make sense? As for population comments…yeah there are 10x the number of people in the US compared with Canada…but there are 20x the number of MDs. So your math makes no sense. As for diagnosis and treatment errors…that has nothing to do with a system but everything to do with the lack of skills from an individual…who exist on both sides of the border.

@clicky What a great reply and contribution to the conversation. I’d like to publish your comments as a column. I will list anonymous as the author. Contact me at vcombs at medcitynews.com if you have any questions.

Really – Are you REALLY arguing that the efficiency of the health care system in America can be improved upon by getting the federal government involved? Is there any entity that is LESS efficient than the federal governement?
Everyone agrees that the system is in need of improvement but the ACA is a poorly written and ill conceived law that will only improve access and quality until the progressive dream of a one payor system is fully realized. I have worked for 20 years in sector of health care that is completely funded by taxpayers. Care providers are paid like McDonald’s employees and turnover is rampant.
A private / public balance is vital to a healthy system. A healthy system requires profitability and there is no shame in that. Aren’t you weary of having millionaires like Obama and Pelosi talk about the evils of profit?

hello_dude has a terrific post that shows the benefits of innovation in a free market economy.
 
When surgery (or any service) becomes more expensive than people are able or willing to afford, then entrepreneurs are in the wings to develop better/cheaper ways to deliver the same services….and make money doing so. 
 
Will technology ever replace anesthesiologists? Who knows? But innovation has certainly changed the way many procedures are performed, making them less risky, permitting easier recovery, and yes, less expensive. Especially when one factors in less time lost from work, shorter hospital stays, etc.
 
The Declaration of Independence does not mention healthcare or any other good or service as a “right.” For good reason. If something is a right, then EVERYONE has an obligation to provide that good or service. Not just “the rich.”
 
There are always a cadre of people who are quick to tell others that they should make less money. That cadre is often willing to use the coercive power of government to take from others for their own benefit. Without the fig leaf of “legality” this is simple theft.

Well, it may be the profession changes to be one that people choose to engage in knowing they will not make tons of money. There are many professions that require advanced education that do not pay what a physician makes today. However, those who chose to go into the profession, understood this. Also, if that occurs, the cost of the education may go down and more people who wish to serve knowing they may never have a six figure salary will be allowed the ability they probably don’t have now. Healthcare as a commodity, to be traded like something on the stock exchange is morally and ethically wrong in my opinion. I am a nurse, not a physician. I see it as a way to serve mankind, not to get wealthy on the suffering of others. We need to have the “right” to healthcare and I beleive it will free up many to have money to spend, spurring the economy to those things that are and should be a commodity.

@JJS
Theres no reason you and like minded folks can’t pool your money and resources to open drug companies, hospitals, medical schools, etc to provide low cost drugs, surgeries, and all the other things that go into medical care.
You won’t, because it’s so much easier to tell other people what to do with their money or talents.
There’s no such thing as a free lunch.

Yes, perspective is everything.
 
What Dr. Smith and “clicky” don’t tell you is that they have 5-10 residents working for them for $10 an hour, billing $50 an hour and up (WAY up) each.
 
Dr. Smith is in the room for the first 15 minutes, and last 15 minutes of each procedure to be compliant and the rest of the time is sitting in the surgeon’s lounge, sipping espresso on a leather couch while watching golf on TV while his residents sit in the procedure/OR room for him. Rarely…RARELY…will you see a practicing Anesthesiologist (post med-school) sitting in on the surgery unless it was a VIP. 
 
 ”Clicky” is luckier, because s/he doesn’t even need to SEE the patient at all in an outpatient setting so can book as many patients at a time as s/he has rooms in the clinic and bodies to perform the “exams”.
 
Stop spreading FUD becuase you fear you will lose your $300K plus (U.S. average) anesthesiologist salary, or $200K plus (U.S. average) primary care salary.

As a fellow PhD, I would think that someone with your amount of education, especially in science and technology, should know that you cannot make good assumptions on faulty data. The #33 world ranking was a fallacy based on subjective judgments from a publication with an agenda to prove , and is not reflective of metrics of quality healthcare many of us would truly accept. Infant mortality is definitely not the right metric, as it is “gamed” by most national systems to appear much better than they are. For example, many nations with socialized medicine don’t even count  severely premature  o low birth weight babies within the infant mortality statistics as they will not be expending the resources to do “heroic measures” to try to save them, as we do in the USA.  We get punished in these subjective rankings for tryign to save even the most challenging cases, where all other countries give up and don’t even count them. Shouldn’t we be using rankings such as: out of premature births less than 30 weeks or less than 2500 grams, how many survive due to excelelnt quality care? We would be at the top. At least for a few more years, until we start sliding and begin to match the vastly inferior but ”fairer” outcome statistics of the systems espoused by socialists.
 
We will get the healthcare we are willing to pay for, and cannot expect altruism out of our most talented and driven physicians. They are like you and me, they are human and seek to maximize their return from their hard work, however they define it. If the opportunities for compensation in medicine become less than in other fields, we should not be surprised if future talented students with biology/science inclinations seek alternate careers in which they retain more independence, better lifestyles, and can hope for a better return on their investment. We will still have a few altruists devoting themselves to care- but how many in society are really born with a Mother Teresa disposition? Not enough to care for all the sick. It is not hard to see what health care system we will end up with when we coerce compasion and altruism and stop providing incentives for phsyicians commensurate to their training and dedication.

Another thing to think about is maybe insurance is the part of the problem. Maybe, if physicians and other healthcare service providers did not have access to insurance they would have to participate in a free market type system. There would be many who could and would pay 300 dollars for a physician office visit, but there would be many more that could not afford that and the competition could begin.

@revenge_of_logic Okay… here’s the data from the Commonwealth Fund, a highly respected organization that most assuredly DOES NOT have “an agenda to prove”:
 
“New York, NY, June 23, 2010—Despite having the most expensive health care system, the United States ranks last overall compared to six other industrialized countries—Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom—on measures of health system performance in five areas: quality, efficiency, access to care, equity and the ability to lead long, healthy, productive lives, according to a new Commonwealth Fund report.
 
“While there is room for improvement in every country, the U.S. stands out for not getting good value for its health care dollars, ranking last despite spending $7,290 per capita on health care in 2007 compared to the $3,837 spent per capita in the Netherlands, which ranked first overall.”
 
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@Walter Mitty So Walter, what about the stories you hear?  Was that a rhetorical question or were you wanting a response?  Those stories are just stories.  When you get diagnosed with cancer in Canada, you are scheduled with an oncologist within 72 hours to map out your treatment plan and discuss the road ahead, they don’t leave you to die.  Quit paying attention to the propaganda and ask yourself if what you are hearing actually makes sense.  You do not wait for life threatening illnesses.  And if you have an emergency, you go to the emergency room.  It’s not a foreign concept.  And yes, an emergency might be something as small as a bee sting.
 
It’s the non life threatening ailments that you sometimes have to wait for.  But if you don’t want to wait, fine, go to the U.S.  That’s your option.  If you have the money and you don’t want to wait 3 months to get a ligament repaired, by all means exercise your right to go elsewhere.
 
I have friends in Canada and in Australia, all on nationalized medicine, and they love it.  But hey, maybe you like your co-pays, followed by your EOB’s, followed by being billed incorrectly, followed by being denied a treatment due to some suit deeming it to be “experimental”, followed by having to spend hours on the phone with the insurance company fighting for it to be covered, followed by having to write the Healthcare representative in your state to help fight the charge… etc., etc.  After spending 3 years of doing that following my wife’s cancer treatments, I’m just not that into it…

This is political propaganda that I would expect to hear from Fox News, and not passed out as a professional opinion. With all respect, your political opinions are NOT facts. Get the numbers right first and then, perhaps, we can start a discussion.

Outcomes on average – are not worse.  If you delve into statistics you will find reporting is vastly different from country to country.  For instance – infant mortality is reported as a singular # – but the statistical collection is massively different from country to country.  Look into how various countries report life expectancy and infant mortality.   
 
There is indeed a tremendous amount of waste.  And very little discussion in actually removing it.  As most physicians at quality indicators – they encourage more waste – not reduce it.
 
The article provides a point of view – calling it ignorant is a straw man.  It is his viewpoint – as valid as yours.  It is a viewpoint that alot of physicians have – they see their income being slashed and their autonomy being challenged.  Many people would respond with similar vigor and disappointment.
 
The politicians have polarized us – and removed the idea having responsible conversations.  Though I disagree with many of his statements – a fantastic book by Woody Johnson – called American Gridlock – should be read by anyone with interest in this manner.
 
Supply & Demand – simple concept.  To bring down price – you need to increase “supply”.  Supply = caregivers.  They are not creating more physicians..they havent been for decades.  They are creating more PA’s/NP’s.  In my own hospital – I have seen a tremendous increase in responsbility with PA’s employed by the hospital.  That is going to be a trend going forward.  You lower costs by having cheaper (PA/NP) professionals providing care.  
 
Two tiered system is what we are likely headed for.  A good system – staffed by MD’s and large amount of extenders (PA/NPs) – who provide solid care – using standard protocols and treatment pathways.  You will also have private hospitals – not dependent on Medicare money and thus federal EMTALA laws do not apply – who will provide higher “concierge” care with all the bells & whistles for those who want to pay more. 
 
If the above paragraph enrages you….realize it is one of the probable endpoints of Obamacare.  Much like there are good restaurants – and very expensive “fine” restaurants.  Government regulates that each meet a minimum standard.  Beyond that – you might get what you pay for.  Or a tremendous value.  Or be ripped off.  That will be up to the individual facilities.

@Thin The HerdInteresting concept. In fact, that’s precisely what insurance companies were established to do, before the money-vultures got hold of them and made the personal cash cows. And for that matter, that’s what Obamacare is attempting to achieve in small part, by spreading the risk among everyone in the giant risk pool we call the United States.

Dr. Smith misses some essential points in his editorial.
1. His compensation is limited by payers (mostly insurance companies)  whether they are federal (as in the case of Medicare/Medicaid) or private (such as United HealthCare, Wellpoint, etc.).  In fact, fees to doctors outside the “network” established by the insurance company are often limited even further.  While one could say these prices are set in “negotiations” between the insurance companies and providers, they are done at a top corporate level and not with individual providers and may not even have much negotiating in them (more “take it or leave it” by the insurance company based on their size, # patients, etc.).  So singling out the ACA as unique in this regard does not recognize the realities of today’s marketplace.
2. Health care costs are way too high.  This was fine when employers and insurance companies were willing to eat those costs, but they aren’t any longer.  Publicly funded systems (such as Medicare) also cannot continue to bear those costs as most taxpayers are unwilling to pay more taxes to support that.  In fact, it is just the drive that Dr. Smith talks about–the drive to seek greater compensation–that drives all the components of the health care system (doctors, medical device manufacturers, drug manufacturers, etc.) to higher costs.  There has to be downward pressure and those pressures whether coming from private interests (employers, insurance companies) or the government are only going to increase.
3. Lastly, the righteous indignation Dr. Smith uses to dismiss the inequities of today’s healthcare system is morally wrong.  Please take a look at your medical bills the next time you receive one.  If you are lucky to have health insurance you will typically see “contract adjustments” on there (these are the items that limit Dr. Smith’s compensation).  Forget about who is actually paying the bill for a moment and just look at the total bill.  In many cases that “contract adjustment” reduces the bill by 80%!  What does that say about the poor schmoe who has a different plan or no plan at all?  Does it really cost 80% more to treat those patients or is it just that since they don’t have an advocate in the board room, they can just get soaked?  While I work for a large company and enjoy certain company discounts, I cannot think of one that rivals the discounts I get through my medical plan.  Either Dr. Smith is losing his shirt when treating me or he’s making a boatload of cash on those who don’t have the same plan that I do.  That Dr. Smith is inherently unfair.  And if you were talking about someone’s cable TV bill that’d end there.  However, if you’re talking about someone’s health or life, well, that kind of unfairness is plain wrong.

@Thin The Herd No, The Declaration of Independence does not mention healthcare or any other good or service as a “right.” The Constitution charges Congress to “provide for the general welfare”, without spelling out exactly what that entails. Is assuring proper healthcare “providing for the general welfare”? You bet it is. Is relegating healthcare to the status of a market-priced commodity failing to “provide for the general welfare”? Again, you bet it is.
 
And FYI, the Declaration of Independence is the document that declared the U.S. free from English rule; it had nothing to do with the laws of our nation. The only rights it specified were Life, Liberty and the Pursuit of Happiness. Although a case might be made that to the extent that healthcare is necessary for Life and for the Pursuit of Happiness, the Declaration DID imply that healthcare is a natural right..

@RobertX   I don’t understand how your comment relates to what I wrote.  Fire protection doesn’t seem all that analogous to food, housing and medical care, but I may have missed something.
 
Fire depts get most of their money from local taxes, so unless we live near each other I doubt much (any?) money has left your pocket to protect my house.
FWIW, in this country’s early days, the insurance companies employed firefighters – taxes didn’t fund the service at all.  I’ve not studied how or why this changed over time, but I don’t find anything inherently wrong with such a system.  Society may have grown too intertwined and complex for that methodology to work on a large scale.

An eloquent and succinct summary of Dr. Smith’s point can be found here:
 
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Yes, David, fire departments get most of their money from local taxes. But that money doesn’t magically appear in the municipal coffers; it’s the proceeds of local taxes. So although I personally might not be paying your firefighters, all your neighbors are. Per your closing sentence, paying a fire department requires the labor or money of another, i.e., paying local taxes to support the department. Your house catches fire, the money and labor of your whole community pays the people who come put it out.
 
Not long ago I read about a community that imposed a $75 annual fire fee. A home whose owner chose not to pay the fee caught fire, and the firefighters came to the scene to protect the neighboring homes while they watched his burn to the ground.
 
Should they have saved his home? Not by your logic. If they had, that would have rendered the whole fire fee optional — how many would still pay it? So fire protection works best if everyone pays for it (in taxes) and everyone benefits equally. Apply that logic to health care. If your participation in health coverage is optional, should they simply watch you die if you elect not to participate?

Not exactly…I’m not sure what you mean but multiple carriers all try to get “contract adjustments”. They are not exclusive to one carrier.  What you are saying does not make complete sense. Is it fair to chisel provider fees by %80 for any reason? I need electricity and gas to heat my home. Why doesn’t everyone demand that these cost’s are reduced by %80? After all, these companies are monopolies anyway with an infinite customer base that has little choice but to bend over and pay the outrageous fees. The original concepts was for large employer’s to negotiate upon behalf of large numbers of their employees to get the best rates. They promised to deliver boatloads of customers and some how, the stupid medical providers bought into this notion that it was okay to get these reductions rammed down their throats by the greedy insurance companies who make staggering profits pretty much every quarter! Where is your outrage for them? If you are discussing the “in network vs out of network” designation, that also is a construct devised by insurance companies to leverage customers to see certain providers and purchase their products. I agree with you that those self pay patients or patients that are out of network do get jammed but that’s not physician’s idea! It’s so funny to me, all of this populist anger should be directed at the faceless insurance company who have been price fixing to make profits for decades! I suggest you write the CEO of BC/BS and ask him if he really need 5 homes, a yacht, and a G5 aircraft? Perhaps he will agree to take an %80 reduction in pay? Only fair…right? People have no idea that provider compensation accounts for 10% of every health care dollar spent in the US! Does it make any sense to attack physicians that represent such a paltry percentage of the problem?  They also have to practice defensive medicine to avoid the vulture lawyers who also are free to drive prices up.The only recourse physicians have is to work for cash…which is happening at a staggering rate with great success in many areas of the country. The powers make it really tough to do but there are many that are succeeding against all odds. Eventually, no one will have access to physicians at all. You will happily get to see a mid-level provider with half of the education that is willing to provide the care for a fraction of the price. Let me know how that works out for you. Widgetizing healthcare providers is the last thing any patient in this country should want to do, you will see:/

@RobertX  @revenge_of_logic 
This, too, is a biased source. A good online rebuttal is here:
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Just like the WHO report, the commonwealth study used subjective measurements meant to rank based on “equity” of healthcare distribution, i.e. socialized medicine, to determine their rankings. The US ranked best in that study in terms of providing the “right” care, but poorly in it’s distribution based on metrics biased towards nationalized/socialized systems.
 
As long as societies with socialist agendas keep sending these out, the misinformation about the quality of US medicine will continue to permeate the national conversation…

“…Among those rights are Life, Liberty, and the Pursuit of Happiness”…I would say that “life” is a result of health and healthcare supports life…so healthcare should be a right.  It should NEVER be based on the whim of the employer (“should I or should I not provide health benefits to my employees?”) which is the system we have now.  And, yes, I do recognize that individual policies can be purchased, but for folks who work for employers that don’t provide benefits, their actual pay is often not enough to afford it on their own.

Robert X…your comments show a lack of understanding of this health care bill. If health care works best when “everyone pays for it (in taxes) and everyone benefits equally” as you stated, they why is this health care bill being carried on the backs of less then “everyone”? Not everyone is bearing the cost. Recent New York Times article pointed out that the cost is being covered in majority by decreasing payments to hospitals and physicians. This appears like a single group is being singled out to carry the burden for “everyone else.”
If everyone wants health care, let them all pay equally. If another service is suddenly deemed a right…i.e. food for everyone…does that mean farmers have to continue to produce food and also accept lower prices for their work just because the majority says so? Your logic is astoundingly self centered. It is all fine as long as you get what you want at the cost you are willing to pay. Heck, given that logic I want a Porsche, and I, and everyone else, should get it for the cost of a Ford Festiva because we said so!

Jared
“If everyone wants health care, let them all pay equally”
Talk about astoundingly self centered!
 
Presumably you have the ability to pay for health insurance and health care. There are millions who don’t, thanks in large part to the collusion between Big Pharm and the health care corporations.
 
How about, “since everyone NEEDS health care, let them all pay an equal share predicated on their income beyond their basic needs such as food and shelter.”
 
No, not everyone drives a Porsche, but most cities, recognizing the universal need for basic transportation, provide free or reduced-cost bus passes for those below a certain income threshold, elderly, and students. Under Obamacare, anyone who wants it and can afford it can have their “platinum” plan (the Porsche), but basic health care (the bus pass) is assured for everyone who needs it (i.e., everyone).

Dr. Smith’s comment are very dismaying to the average consumer. Anesthesiologists average $360k a year according to their own surveys(see Profilesdatabase.com).  Dr. Smith is a well known conservative commentator.  Maybe he can go drive a truck or be a nurse if he can’t afford to be an anesthesiologist.  Obamacare is not perfect, but it helps a lot of people.  Since day one, some conservatives have only worked toward reversal of this program because it was passed by a Democrat.

@RobertX Tax-funded fire protection doesn’t really compare to food, shelter and health care.  Most of us will probably never use it, but we appreciate its presence.  I know the story of the house that burned while the firemen watched because the guy didn’t pay the local fee.  A better solution (in my view) would have had them putting out the fire, with the resident having to pay a much higher charge, much like a ticket.  IOW, you can opt not to pay the $75 up-front.  If you don’t, the fire fighters will still douse your house, but you’ll pay $500 (pick a number) after the fact.  I prefer this more direct approach to paying for what we might call municipal services, but I haven’t the time or inclination to push for change in that area.  And if you decide to bring up the police, I’ll state now that I think the protection of property rights and the administration of justice is one of the few legitimate functions of gov’t.But your analogy doesn’t answer those questions posed by mine.  If we need food and housing for our very existence, does that make them “rights”?  If yes, then why must we pay for them, and why would a person who steals them incur penalties?  How does medical attention differ from these two basic human needs?

@revenge_of_logic Absolutely right… the U.S. has the best health care MONEY CAN BUY. But if you’re not fortunate enough to be able to pay through the nose for that health care, you’re pretty much on your own.

To assail Medicare ( a program my parents, who worked their entire lives, receive) smacks of the arrogance and greed we have allowed for far too long in this country. Why. just ask our Canadian colleagues the reason for their migration south to the U.S.—cash all around!
The American people are better off with providers ( whether they be M.D.s, NPs or PAs)- who desire to do what they were educated to do—regardless of payor status.
 An interesting last note–ask Dr Smith who’s been paying for all of the uninsured whom inevitably have to use medical services at some point- often catastrophically.! The American tax payors are already “eating” those bills–hence, our costs would have skyrocketed far beyond what ObamaCare will cost.

@Thin The Herd Yeah, but you conveniently miss the oath we take to provide care and do no harm….let’s see if you would have same perspective when your parents, as mine have experienced, are refused b/c they are retired  and receiving Medicare. They worked their entire lives for this?
Making an argument for us middle class folks to continue to  bear the brunt of higher taxes due to the uninsured using medical services, often catastrophically, so that others can profit–is unethical.
Just like the rich paying 15%—gaaahhhhhh..really?

average med school debt is 160,000 at graduation  — add that to another 40,000 undergraduate debt and the fact that between internships and residencies you dont hit the job market until your early 30′s — giving you a career of abou 35 year max.   (remember 22 year old beginning engineers with a fraction of the debt start in the mid 60,000 range.  add in malpractice insurance, what would YOU do the job for?  Remember most advanced professions do NOT require the expense or training of a physician
 
BTW: i  am a system analyst with 35+ years experience making under 140000  — stop the envy

Hi Dr Smith,
I applaud you as one of a few brave doctors to come forward and speak plainly on this subject.  I work in the medical field…and when this merry go round of a healthcare bill eventually stops and we as a nation are worse off economically and morally as a nation for it., the government will be the caretaker of it and turn it into yet another bureaucratic, inefficient monster.

Vincent,
Please do us viewers’ a favor and discuss the facts instead of bashing the news source.

And physicians who spend 8 years in school doing nothing but studying their ass off followed by an additional 3-7 years in residency working 80 hour weeks making as you stated, “$10/hr” are not entitled to make a decent wage? That’s just looking at the amount of education and training they have. Many have also racked up several hundred thousand dollars in loans between undergrad and medical school. Then there is malpractice insurance and continuing education costs…….

I think you, my friend, are missing the point of the doctor’s article. It wasn’t about level of compensation so much as it was about enforced servitude.You pointed out the “morally wrong” position of the doctor’s indignation, but if you believe you have a “right” to someone else’s services, I believe you are the immoral one. You don’t have any such right. No one does. Do you have a “right” to my ability to provide a process-improvement service? Of course not.
 
Second, how high is “way too high”? What right does any patient have to the years of training, education, skill, and experience provided by someone in the medical profession? If it’s a “right” (and that’s a mighty big “if”), shouldn’t it be provided for free?? If that’s the case, is any medical provider anywhere permitted to charge for his or her services? If it is, in fact, a “right,” isn’t a token charge of even a penny “too high”?
 
Finally, if I walk into a doctor’s office without insurance and advise up front that I’m paying cash and that I’m responsible for the entire bill, and if I then request a discount for cash payment (as I did for 18 months when I was self-employed and without medical coverage), I’m usually given a substantial discount, sometimes up to 50%.
 
By the way: I chose to go without insurance. It wasn’t withheld; I made a conscious decision to not purchase it. Does that make it unfair if the doctor gives me a 50% discount and gives insured patients an 80% discount? If so, why is it unfair, since it was my own decision? To whom is it unfair? Me? No; I chose an available option. The person who pays less? Perhaps, if they were forced by some legislation to choose one option instead of another that they preferred, and which would have been no less moral.

@novastar1967 My recommendation is that you take a college-level course in basic economics.  If you’re able to capture the principle of cause-and-effect, you’ll soon see the fallacy of your position.

“If something requires the labor or money of another, it does not qualify as a right”  So our expensive legal system is not a right.  Air would be, water would not.

I agree that doctors should be paid for their work. However, I’m not sure how much doctors should be paid. A billionaire may consider $500K chump change for heart surgery which he needs to continue living. But the average Joe in the 47% or even the 99% is not going to be able to pay even $200K without some help. Maybe Joe just needs become a benefactor of a billionaire.

Dear Dr Smith:
Your rant tells us more about you than about healthcare.  And it is a rant.  Healthcare is too darn expensive. And Obamacare does not guarantee healthcare but only insurance to pay for healthcare.  You  sound as though you need a change of professions,  This is the twentyfirst century. And it is the USA.  Last time I heard, no one guarenteed you a job.  If you need to work harder and smarter in your profession so be it.  You should probably take another look at the panels provided for in Obamacare.  “best practices” has been an accepted way of improving healthcare for several years.

@clicky What percent of the population (300+ million in the US, 7+ billion people in the world) make $1/hour, $10/hour, $100/hour, $1000/hour, $10K/hour, or $100K/hour? How much could each group afford to pay for heart surgery?

Dr. Smith ignores the fact that he works in a profession that intentionally limits the number of people that can do his job so that he can charge an above market price for his services.  He makes no mention of the fact thas his profession actively takes money out of his neighbors pocket because they artificially keep prices above the market.
 
Now we, the people, have allowed this to happen because we don’t want just anyone that hangs out a shingle to be able to practice medicine… we want the certainty of only qualified individuals   But we should also be asking the question that should we be allowing a professional organization that has a profit motive to reduce the number of practitioners to be the ones to set the standard…. Might they keep the number too low so that their members might make an above market price?
 
‘Physician, heal yourself’

That is the worst article I have ever read on this! I mean it is biased and surely politically oriented. Why this doctor even chose to be in medicine. Sir, if you want to be rich then medicine is not the place to be. This is the most ridiculous article ever. There is nothing else mentioned here but greed and no empathy.

@emdocarizona 
 
Supply and demand doesn’t really exist in health care except for cash based services such as cosmetics, lasik, dentistry. More supply equals more utilization. PA/NPs do not bring down costs. Hospitals employ them and  pay them less but bill the same for their services as they would for a physician’s.This makes more profit for the hospital but it will not decrease healthcare costs. PA/NPs increase utilization and order more tests and more specialist consults further driving up costs but helping the hospital’s bottom line.

$300k a year is not a decent wage?  I have my masters degree, with $100k in debt, took 10 years to achieve that, and make $50/hr. Should I be “entitled” to more? 
 
And the figures I represent are the SALARY, not the income of the practice.

@bob the programmer Not sure who your comment is directed towards, but here’s my story.
 
As I mentioned in a reply below, I have my masters after 10 years, with $100k in debt, and started my career in my 30′s. I currently make $50/hr (salaried, but around that). I work in healthcare. Why do I do it? The reason many in healthcare do, because I feel as though I’m doing meaningful work.  
 
I certainly don’t make $300k, and probably never will. This doesn’t include the bonuses involved in hitting targets, speaking, teaching, etc. that most medical professionals (Doctors and the like) get.  Dr. Smith certainly needs to curtail the envy…

@DrVanFaulk To only talk about efficiency is foolish, and on that end to assume private companies are more efficient is laughable. There is no correlation between private/public and efficiency.
 
I can only assume, as most Docs I work with, you have little clue as to the reforms that have been put in place as a whole by the current administration. You mention ACA, which part? It’s huge. And BTW, it’s the PPACA, folks like you always forget the Patient Protection part. But why would we want to protect the patients at all, right? In addition there are provisions in the ARRA, specifically HITECH, that certainly are making healthcare organizations more efficient and profitable. 
 
I’m curious what sector of HC you work in? I work for a non-profit and we pay ridiculously well, even though our payor mix is hugely weighted towards Medicaid and Medicare.
 
No where did I mention profits, or having shame in that. What I mention is that to have a person who works in a position where the average salary is $300k complaining about their compensation being too low is sickening.

Again: Not about level of compensation! This is about a legislated requirement that someone provide a service. Does this not take away an individual’s right to lead his or her life as he or she wishes?Dr Smith is not complaining about his level of compensation. If he were, wouldn’t it be somewhat disingenuous in light of his comment that he stopped an area of practice due to someone else’s immoral demand that he provide his service? How much does he get paid if he stops practicing? Is it more than or less than he gets if he practices?
 
This is not about how much someone gets paid for providing health care. This is about the right to practice or not practice. See the 13th Amendment.

I am a middle-aged, middle-class, single, childless, well-educated, African-American woman.  During the recession I was unemployed/underemployed for nearly 3 years. I did not utilize Medicaid during that period of my life.  I either self-paid or didn’t see a Doctor. I probably will utilize Medicare when I am elderly (if the program still exists). I have and continue to be a polite and respectful patient.
I agree that Doctors ought to be paid fair market value for the Healthcare services that they provide. Yet, in my experiences with Doctors, I have paid premium rates for poor or no Healthcare for most of my adult life – not just the 3-years of unemployment/underemployment.  While the majority of Doctors I’ve seen have been happy to take top pay from me directly (when I was uninsured) or from my insurer, for their services, they have failed to take care of me. Additionally the lack of care has been delivered with the upmost disrespect.  Examples of this include, me showing up early only to wait up to an hour or see the CPN instead of the Doctor or rearranging my work schedule (which by the way, if I don’t work, how can I pay the Doctor?) only to have the Doctor leave to attend to a patient in the ER without notifying me at check-in.  The majority of Doctors I’ve seen don’t listen to me.  They have missed medical conditions that have caused me to suffer, needlessly, for over two decades.  And then there are the Doctors who game the system – yes, I’m talking about Fraud.  In what other industry could such lack of productivity and unethical behavior go unchecked?
My experiences and this article, lead me to conclude that most Doctors just don’t want to do their jobs and still get paid, regardless of the medical and financial consequences to patients.  While “Obamacare” may not be the “perfect” solution to providing “choice” Healthcare for all citizens, I argue, that it is not the reason why the author of this article and Doctors like him, are moving away from serving elderly and poor patients – and eventually middle-class patients.  I appreciate the Doctors don’t work for free.  And I also believe the many Doctors get paid for nothing.  That being stated, it would be helpful to hear from someone who is honest about U.S. Medical Practice as a for-profit business industry that requires solutions for patient advocacy and practitioners’ ethics.

The level of compensation IS a factor. However, compensation is not the only factor. Doctors need patients and patients need doctors. The price of health care needs to be fair to both the doctor and the patient. Of course, the devil is in the details, what price is fair?

@GShelton The profession of medicine – Practicing Physicians  - do not set the number of graduates nor the number of schools producing physicians in the US.  That would be the AAMC which is a large bureaucracy located in DC & your government at work.   
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[8]
 
  From 1979 to 1999 – only 5 new schools were created.  Since 2000 – there have been about 20 more created – with another 20 in “development” according to that infallible website Wikipedia. Why are new schools being created? They make money – our government is willing to loan obscene amounts of money for secondary education – and with that a bubble is being created.  Because the government lets you borrow 50-75K a year – magically – the price of med school is around 250-300K for the four years.  (amazing how price meets the supply of money.  housing crash anyone? wonder why college is so damn expensive? they know the students can get the money from the US government.  I digress.) 
 
Why most physicians fear government from stepping into the management field of medicine – is we already see bits and pieces of it coming through.  (Blanket statements of republican hatred, racial bating, or that physicians are taking money out of their neighbors pockets arent really useful to a good natured discussion in my opinion.)
 
Lets look at some government initiatives into the field of medicine.
 
Quality indicators can & do  encourage more waste.  Want to screen for more sepsis patients? = 7X more blood cultures in our hospital alone.  Each culture runs about 200-300 dollars.  Ask most ER physicians if they think it matters…or find a study where it shows it matters.  There are rapidly expanding “indicators” which hospital systems are monitoring and therefor testing.  Many of these have very dubious data behind them.  The pendulum has swung from the logical “monitor the solid indicators that are rooted in good data” to a more is better phenomenon.
 
The push towards more Primary Care Docs so more preventative care can be done.  Find the sparse literature support that preventative care saves money.  It costs money. 
 
ACO’s -(not ACA – Obamacare – but Accredited Care Organizations)  the new trend – do not save money.  They are being touted as a way to “increase efficiency”. Yet there isnt much evidence they do that.  Nonetheless – we move forward to them.  We do this because government is putting money behind them in order for their development. 
 
Electronic Health Records – hospital systems are spending billions (with a B) on IT systems.  IT systems which do not converse with one another/are tragically flawed/do not improve safety (in some studies – actually increase risk)/and potentially could be defunct if there is ever a standard set by the government.  Yes – our government has pushed for EHR – without setting a standard in which they will all communicate with one another.  What good is my hospital system electronic record if you are visiting Topeka – and cant pull up your records?   Why do hospital systems spend billions – because the government is reimbursing them (partially) to get it done by 2013/2014.  Even though none are truly ready for prime time. 
(DISCLAIMER  - STUDIES have shown savings for office based EHR…not hospital based)
 
Bundled Payments to hospital – hospital gets one check to split amongst themselves, and the multiple treating physicians.  If you need an invitation for dysfunctional relationships – it doesnt get any bigger.  Why is this occurring? Because government is pushing it for Medicare payments.   http://www.innovations.cms.gov/initiatives/bundled-payments/index.html
(read the “reason” behind it.  If I told you – your entire office staff was going to get paid a singular amount for a days worth of work.  And then it was up to the office to figure out who got paid and how much – tell me how you think that would improve your day to day functioning)
 
Lastly – medical malpractice reform.  Tort reform.  The single most desired thing that most physicians would HAPPILY forego 10% of their current income to get fixed.  Our government has led the charge. 
Oops.  
The AMA has led the charge.
Oops.  
Not even a mention during the prior 2 years of Obamacare debates.  Hell why would you – that is only going to cut into the income of trial lawyers and the legal system.  Not to mention – it would actually improve care by ALLOWING physicians to actually FOLLOW proven guidelines.  Most of us don’t – because a guideline doesnt protect you from the 1% of patients who have a rogue illness that defies the typical guidelines of treatment.  Thus we spend millions searching for the Zebra’s.  You cannot put up the Ottawa Ankle rules in a court of law if you missed an ankle fracture on a 22 year old athlete.  Write the check. 
 
The list could go on. The list of cost saving accomplishments our government has succeeded in the past 2 decades is a small one.  (anyone?) 
 
ACA may save the uninsured family being bankrupted.  We all would somehow like to prevent that.  But is there a better way?  Couldn’t we have even had that discussion?  
 
The unintended consequences of the ACA – are what I think Dr. Smith was writing about.  Mainly – the many highly qualified excellent physicians who will choose to practice medicine in a way that they are removed from government reimbursement rules.  This means concierge medicine on a much more massive scale.  This equals a two tiered system – I have yet to see anything that convinces me otherwise. 
 
More intelligent conversation has occurred in this forum than it did in Washington DC for 2010-2011.  That is a sad statement.  Or it means we could all be US Senators & Congressmen/women.
 
Cheers

@cyclone  
Medicare & most insurance companies will pay LESS for services rendered by a PA versus an MD.  It is why you see many Physicians “touch” a patient then pass them off to a PA – so they can billed at physician level charges.    But it is illegal to bill physician charges when an MD/DO has not treated the patient.  
 
Also – bundled payments for “entire visits” – meaning your entire healthcare encounter – are coming down the road.  This prevents bill inflation from ordering tests/etc.
 
Think on grander scale – hospitals are moving towards physician employment once again.  Physicians cannot survive in solo practice anymore with ease.   Replace 50% of those employed physicians with employed NP/PAs.  You have just cut your hospital payroll by a significant amount.
 
I didnt really explain my comment in detail – but the government is going to decide to pay less. When they do, there is not much a hospital can do.  If Medicare states they will pay you 115 dollars – arguing with them is pointless. Your getting 115 dollars. 
 
As the government reduces payments – the insurance companies will set their payments as a certain % of medicare (this varies widely across the industry).  All payments go down. 
 
This means hospitals will need to find a way to do it cheaper.   How do they do it cheaper? They do it with cheaper workforce.  
 
I agree with you that it is an unnatural supply & demand – because you have the middleman (government) setting the price point.  I will also agree with you that undirected – a PA would likely order more tests than an MD and drive up costs.  It is why I think “protocol” medicine is going to be the standard of healthcare in the near term future.  
 
Thanks for your comment.

@Process2Succeed No one is going to force him to practice.  He just mentions that a Physician was going to “Try” to make him do it.   That is the Physician trying to pull political muscle.
 
I am sure he feels that he is being forced because medicare makes up a big part of Healthcare and he has elected not to take Medicare any longer.   But the Government is not holding a gun to his head.  its his choice.
 
And as he said… if someone did try to force him all he would have to do is explain to the family that he did not want to be there and everyone would end up with Egg on their face.

Based on the people posting here who are clueless about reality and what it means to be FREE, I can tell you with certainly that this country is quickly devolving into a state of tyranny.  Most will scoff at my comment, but someday all will know it to be true:  We have trodden underfoot the 10 commandments and forgotten the least one.  Disobedience to this command is tearing our country apart:  You shall not covet.

@Justin Hurley
 Justin- I hope that a truck driver is not in charge of your anesthesia the next time you need surgery.

@RobertX  @Thin The Herd
 RobertX-  While I certainly appreciate your perspective, the RIGHT TO LIFE was written into the consitution because the British thought they could KILL anyone who stood against them in certain circumstances without due process or legal proceedings.  The Declaration spells out these autrocities.

I am a hard working student with a 3.0/4.0 GPA from a state university, after transferring from a community college, at which I spent 4 years because I kept failing classes. I just recently got into a top 20 US medical school. I thank all the smart students for dropping pre-med and choosing investment banking so that I could get into a good medical school.

@cyclone  @emdocarizona This is an untruth NP’s are paid at 85% of a primary care provider only! They do not order more tests in fact they order far less,they are look to labs that are more cost effective such as Quest or Labcorps instead of the big hospitals that gouge!
Second, if we were not losing money paying for illegals here in this country we could save a bundle. Check and see how much Homeland security spends on them while they are here. Then check to see how many obtain WIC for their anchor babies, Medicaid for the same. Keep going. Wonder why Mom and dad cannot count on medicare?

@clicky THANK YOU, DR! I AGREE 100%. I am a NP and I understand completely. I’ve been in the nursing field 35 years and believe health care is a privilege not a right. Why is it that no one complains when pro athletes make millions and there are many that can bare speak the English language but heaven forbid a health care professional make a decent living after breaking their neck to attain one of their many goals in life. With out Tort reform doctors have to cover all bases so this has driven costs upward. If you put into place decent tort reform so ambulance chasers and their clientele cannot get  ridiculous amounts of monetary awards you could have much lower costs.
 I am not envious of someone making more money because he/she has worked hard to receive an education, and continues to work hard daily in their profession.
 
I m opposed to handing out freebies to individuals quite capable of attaining goals but have no desire except to live off of others and expect to have things handed to them.
I am also opposed to having little old folks go without medication or care because of these same freeloaders.
I would much rather see Medicare survive then Medicaid unless it covers only those that can others wise cannot care for themselves. ( Special needs,  and truly disabled)
There is a test Rehab sites can do to assess a patient for disability. It is worth every penny.
This is another reason  why health care costs so darn much.

Bravo.  You nailed it.

@GShelton ”his profession actively takes money out of his neighbors pocket because they artificially keep prices above the market”  
You are misinformed.  Physicians do not set their own prices (except for those who do not accept insurance/Medicare/Medicaid).  Physicians who accept payment from these third party payers have to accept the fees allowed by those plans and they cannot ‘balance bill’ for the difference between their stated fees and the fees which the insurance plan pays.  The insurance companies dictate ‘the market’ and this has cause the gross inflation of fees.  Do you really feel that Dr. Smith’s reimbursement of less than $50/hour for extremely complex care is excessive?  Really?  
 
 @DonW ”A billionaire may consider $500K chump change for heart surgery which he needs to continue living. But the average Joe in the 47% or even the 99% is not going to be able to pay even $200K without some help.”
You’re right, the total hospital costs for some procedures are extremely expensive, although I don’t know where you got those particular numbers.  But you are WRONG if you think that’s what the physician makes.  The total hospital charges may run into the $100,00 range for such a procedure, but the surgeon’s fee is the ‘chump change’.  One famous example of a politician deliberately misleading and inciting anger towards physicians is Obama’s speech at the Portsmouth, NH town hall meeting in 2009:  ”… if that same diabetic ends up getting their foot amputated that’s $30,000, $40,000, $50,000 immediately the surgeon is reimbursed.”  OUTRAGEOUS!  He knows (or should know) damn well that as per current fee schedules Medicare pays the surgeon only $871.20-$1091.59 (depends on geographic locale) and that amount includes the preop care, the surgery, seeing the patient every day in the hospital, and 90 days of unbillable care after the surgery.   Look it up for yourself.  CPT code 27880, below-knee amputation.  Perhaps he misspoke or was misinformed, but a correction or apology was never issued, leaving the public to believe that rich greedy doctors are the reason heath care is so expensive.  Sigh.

GShelton…intreesting post, but doesn’t this point to a in Obamacare…..access? To your point, a capitalist would see this as a supply and demand problem and invest more money into medical schools supporting which in turn would add more phyisicians the market place and thus increase competition, lowering prices. Instead, Obamacare assumes throwing more “underinsured” patients at the same limited supply of physicians will solve the problem. Socialist thinking v. Capitalist thinking.

@Walter Mitty How can you get an accurate poll, when people have experienced nothing different?

@GShelton Its amazing the hubris from the left. You think its some small task achieving what this man has? Then do it yourself. Who are you to judge what is in his heart? The only “limiting” factor here is the intellect and hard work it takes to complete a medical degree, otherwise everyone would have one. What an incredibly ignorant, ungrateful, and selfish comment to make. If this is such a “common” practice and our choice of healthcare should be as arbitrary of a choice as you suggest…why not call that jackass in the white house to provide anesthesia?

Dr. Smith has, wittingly or unwittingly, tapped one of the roots of the health care problem in the United States.  As he correctly states, as a physician, he has the right to refuse any set of patients he pleases.  Hospitals, on the other hand, have the legal responsibility to take care of anyone and everyone who shows up at their door.  This leads to 2 problems: 1) an influx of patients using the ER for primary care services, because they either cannot find a physician who takes their insurance or it is just more convenent (and expensive), and 2) this gurantees that any single attempt to solve the healthcare crisis will be unsuccessful, because of this 2 tier system.  This will never happen, but I believe that the first step that should be taken to extend healthcare to all is to extend EMTALA (the legal requirement that one must take care of any patient who shows up) to ALL healthcare professions (including physicians).  This will level the playing field, and make any financial decision regarding healthcare equitable to all providers.

@hello_dude Since you are a techie, can you invent a machine that will turn a patient and clean them, change their linen after they have soiled the bed? By the way, you won’t understand until you’re mom, dad, kids, love, or you are in a situation that prays for a competent care staff, especially a doctor, to save your life or quality of life. The nurses, aides, secretaries, etc. all know and let it be known who they want, and don’t want for a doctor “in case” they end up on the other side of the side rails. As an RN in intensive care, I have gone through costly additional training. I also just received a $2/hour paycut. I don’t just push pills and paperwork. I give my ALL to my patients and their families. It is an emotional, psychological andphysical stress. Ican only imagine what it is like to be a doctor and have lives in your hands. You better hope he cares and has the knowledge to pull you through.
What everyone fails to realize in this healthcare debate, is the human element. It can’t be measured, it can’t be replaced. No matter how many inventions there are. On top of the pay cut, we are down from 30minutes to TWELVE minutes for shift report. I can only dread what this will do to patient safety. This to me is most troubling.
So, when it is your turn on the wrong side of the bed rails, remember your snarky comments and put a little sugar with your bitters. You better pray you can get the help and compassion you need and deserve. We all make choices, I am happy with mine. But don’t hate people for making choices where they get paid better than you, for an invaluable service they provide. Fair pay? Who is to really say what is fair. And who is John Galt?

I don’t see your logic.  If YOU don’t want to offer services to someone then YOU don’t have to.  Obama care does not say ANYWHERE that they are forcing providers to offer service.  So stop trying to use fear tactics and plan foolishness to try and scare people into not wanting obama care.  And by the way your beloved Mitt Romney had the plan developed first in his state.  From what I hear it worked fine.

Process2Succeed, It is precicely about how much he gets paid and not about the right to practice.  His direct quote is “I stopped doing cardiac anesthesia, because well over half of the patients were ’covered’ by Medicare and payment to me for my services was well below what I thought acceptable”.  THAT is why he stopped accepting Medicare.  I agree with you that his reasoning makes his claim disingenuous.  ”SLAVERY”!?!? Get over yourself Dr. Smith, no one is standing over you with a bullwhip.  They are only providing you with competition.  If you can get patients to continue paying you what you think acceptable when they have an alternative, more power to you, but to try to eliminate competition to artificially inflate rates is extortion.

@holmesmd1 ha! does an md need 5 homes, a yacht, and an aircraft?? It’s not just insurance, it’s the greed of the medical community. Profit is the first and foremost goal, not the patient. And the medical community is afraid of the new medicare regulations that force the medical community to keep people out of hospitals, prevent readmits, and force them to CURE the patient, not put a bandaid on their symptoms, so that they can keep coming back for more services. For-profit medical care is a gross conflict of interest regarding acceptable patient care. Have you checked outcomes in all the other developed countries who have socialized medical care? Um, get your head out of the sand. The American health care industry is doing a poor job, thus, Obamacare had to happen.  Yes, the physicians might make 300K instead of a mil a year, I think they can live just fine on that income. Don’t you think? This country will NEVER lose access to physicians, that is just an irresponsible scare tactic.

@Walter Mitty don’t listen to the media, check the national statistics on the Canadian health care system and their outcomes. There are also stories of Americans crossing the border to Canada who could not get health care in the US.

Though I do not know how this will be handled, I can say that I spent a couple years in England, where I watched “free healthcare” first hand. The service was poor, there was always a wait, even if it was intolerable pain. The QUALITY went way down. Health care needs to have a high quality of service. I always say quality over quantity.
 
Though I am doubtful, perhaps America will do it better than England. I know for me, I am intelligent enough to make my own healthcare choices and I dont need the government to treat me as a number and boss me around in my personal matters. We already assist those without insurance. My first years in employment without any education or experience I couldnt afford insurance. I did get free charity care. The government paid for my hospital visit where I had kidney stones and I paid nothing. There are still programs available for those in need. So why are there so many complaints? Lets get real. We ALL complain about the “worst” things in our lives. There will always be something we want better than we have.  At some point, the citizens with a hard work ethic will get tired of being taken from and you will see people becoming poorer and poorer as they in a sense “give up” working for what everyone else is seemingly getting for free. The way I look at it, is everyone reading this, has more than the majority of the world. If you are one of those complainers, you should look around and be grateful for all the blessings you have in your life. Someone has always picked you up- even with your health care. Id like to make my own choice. All due respect. Thanks. -Jen

@Calamity Sane  @clicky If I cannot go to see a basketball game because the cost is too high, I am unlikely to die from it. If I cannot go see a doctor because the cost is too high, there is the possibility that I could die from it.
 
As for tort reform, what a fallacy. Look at studies, such as those from the University of West Georgia and the State of Mass.  
 
Direct premiums per doctor have DROPPED over the past 3 decades.
It has been shown that the value of the TBill has more to do with insurance premiums than tort reform.
Approximately 33% of filed lawsuits result in payouts for individual doctors
Market loss ratios for insurers have dropped by nearly half or better in the past 2 decades
Over HALF of the states in the U.S. already have some form of Tort reform, and many have had tort reform for decades
 
With current reform being enacted, Doctors will not have to “cover their necks” because they will be 1. better prepared and informed during care 2. under scrutiny to ensure they are doing their due diligence 3. performing best practices, and not guessing or inflating numbers by ordering unnecessary labs, meds and procedures.  This in turn will lower costs, as will driving new demand in to the market.

@emdocarizona ”Supply & Demand – simple concept.  To bring down price – you need to increase “supply”.  Supply = caregivers”
 
Simple concept that you completely miss the point of. Why would supply increase if DEMAND doesnt?  
 
Simple concept, with Obamacare there will be more folks covered by insurance.
Simple concept, folks covered by insurance are more likely to see a primary care for preventative care than show up at the ER when it’s too late and very expensive.
Simple concept, more folks showing up to PCPs is MORE DEMAND. More demand calls for more supply. More supply means lower prices.
 
Econ 101. You can pick up a used textbook for around $1 on Amazon.com.

We live in a pseudo-capitalistic society.  Doctors cannot and will not work for free any more than an autoworker shouldn’t have to work for free.  But here is something that most physicians (and indeed most healthcare professionals) are reluctant to admit – they are paid a fee for service regardless of the quality of service provided.  This provides a financial incentive for healthcare professionals to see an ungodly number of patients in a day in order to drive profitability.  Instead of supporting the development of outcomes-based insurance systems, they cling to the broken system which promotes mediocrity in healthcare – the one part of everyone’s life in which mediocrity is least tolerable.  The American fee-for-service healthcare model was broken by the physicians lobby, the AMA, and now the same lobby is trying to prevent the repairs necessary.  First off, it is important to identify the strengths and weaknesses of a physician.  The strength?  Unparalleled knowledge on the diagnosis of maladies.  The weakness?  Everything else.  Doctors are certainly NOT experts in all areas of medicine and it is time they cease pretending to be competently knowledgeable about para-medical subspecialties in which they have no formal extensive training.  Is a doctor an expert in the methodology of physical rehabilitation?  No.  Is a doctor an expert in determining the appropriate pharmaceutical regimen for a patient?  No.  Is the doctor an expert in guiding a patient through nutritional matters?  No.  Those are the jobs of a physical therapist, pharmacist and nutritionist/dietitian, respectively.  The same is true for non-physician practitioners as well.  The pharmacist, who is a doctor of pharmacy and trained on the medically appropriate selection of pharmaceutical therapies, is primarily responsible for the dispensing of medication in a model in which they are reimbursed solely on the basis of the drugs dispensed – not on the basis of the knowledge imparted on counseled patients.  Just as a physician cannot effectively do the job of a pharmacist, a pharmacist cannot competently do the job of a physician.  But as a non-physician practitioner, I can assure you that approximately 20% of my patients are receiving medically inappropriate care from their physicians and in some cases, medically dangerous care which I vocally oppose and refuse to provide.  The new model *must* reinvent the healthcare system into one in which the primary care physician remains the keyholder to all the doors of healthcare and remains primarily responsible for developing individualized health strategies to be implemented by other healthcare providers in order to improve the state of a patient’s health.  In return, the all the healthcare professionals involved in the care of the patient are reimbursed nominally for providing the service, but are rewarded for improving the state of health of the patient based on the practice of evidence based medicine.  For example, if a patient was to be newly diagnosed with diabetes with an initial A1C of 9.0, the physician would paid a small fee for their ability to make the diagnosis.  Once diagnosed, the physician should establish a healthcare strategy to be implemented.  Let us say that the strategy calls for the patient to visit a nutritionist to be counseled on diet, a physical trainer/diabetes rehab specialist to increase their physical health, and a pharmacist for counseling on the medications.  Each of those three professionals would be paid a small fee for service.  Guidelines based on the evidence-based medicine establish the goal A1C to be 7.0 (which really should be lowered to 6.5 to math UK standards) in order to prolong a state of health and stave off debilitating and costly medical interventions (diabetes is the leading cause of kidney failure, amputations, and blindness, and a leading cause of heart disease, vascular complications, and neuropathy).  Therefore, if the care provided to the patient lowers the A1C by an established rate (for the sake of argument 0.5 in 12 months), a fee is paid for lowering the long term risk for the patient.  Once the A1C is lowered below 7.0, additional reimbursement is provided.  For every year in which the A1C remains at goal, additional reimbursement is provided.  This system of reimbursing for surrogate outcomes promotes a system in which the highest paid physicians and practitioners are the ones who best utilize their colleagues to collaborate for the care of a patient with the sole objective of improving the patient’s state of health.But no medical lobby would support such a goal… because it is not nearly as profitable to see healthy patients.  And therein lies the issue.

@Process2Succeed
I have never had success getting a doctor or medical practice to lower their fees based on me not having insurance. And now I have a plan (beech st) that has extremely limited doctor choices in my area as an example in my prior insurance (bcbs) there was a choice of over 900 neurologists but with my current insurance there are less than 9. Why is that? It’s about compensation. When I see doctors out of network, I am charged full price for all things. Therefore I have tried to negotiate, most doctors make the following suggestions 1. Go to the ER (for routine problems) 2. Pay me full price if you want to keep seeing me 3. Find a new doctor. FYI the contract negotiated price might be 50-80% less but they get that back from me by balance billing. This IS about cost and this IS about doctors wanting more money. But their arguments sound childish to me…he’s complaining about a pay check but for me this is about my life and my health. Why would you choose a profession that requires face to face interaction but not like helping people enough to help the difficult ones?

@DaveKerns  @GShelton the other problem is… if it is such a wonderful plan, how come the senate, house, and president are exempt from it?  Why do they think they should have “premier service?”  If everyone else in the US is required to be in the plan – they should be first ones in!

What does the “5 pts” notation next to some names mean?

If you read my comment – it was in regards to LOWERING the cost of healthcare in total.  Obamacare is rapidly increasing the demand – more people with insurance creates more patients at PCP offices.  You have that correct kimosabi.
 
If you create more demand – you have to massively increase supply to drive prices lower.  Otherwise you go up on that little X curve (I am sure it is in your 1 dollar amazon book – if it isnt – let me know – I will draw it out for you)
 
The supply side is where I think the SWITCH will occur.  Physicians – you are hearing from some of them in this thread – are not terribly excited to continue to see patients at the current medicare rates (which is what the newly insured will be paying).  So – where is the supply coming from.  It is coming from NP/PA increases – IN MY OPINION.  This is a place for opinions right?
 
So – the original post was to remark that I thought our system was headed towards a massive increase in patient care by physician extenders (PA and NPs).  Thats it.  
 
Appreciate your snarky comments nonetheless.  Will you buy me that textbook?

OK, there are so many different views regarding healthcare depending on which side or angle of the fence you are on. As a person that has worked with physician since 1989, I have seen so much. I am also a mom, taxpayer, self-insured health insurance patient. Being the entrepreneur and small business owner, selling to the small medical office, (now becoming extinct), I have seen a progressive change in the way billing has been done to the insurance company and patient. Yes, 25+ years ago there was (I my opinion) so much money being made for the doctors that many were even sloppy in the accounting/business end of their practices. Labs being ordered and processed in the doctors’ offices then government studies showed this to be excessive; hence they put a stop to that. Government did studies and found that fees were excessive to fair market, hence set fee schedules. All other insurance companies have since followed that same fee schedule model, setting a maximum fee re-imbursement rate of all providers in their networks. If doctors (again my opinion) would have group together to create standards for their specialty’s and fought for their individualism maybe it would be different today.
Doctor’s are no longer making the big bucks; they are setting their rates higher and higher in hopes to get the insurance companies to hopefully pay at a higher percentage.  They have grouped together to form larger groups again in the hopes to comply with the demands of the insurance companies that have been threatening them since the 1st healthcare reform attempts by Hillary 12-15 years ago.
No one was watching during the first round of group formations as the insurance and pharmaceutical companies grew and grew.   I have an opinion and it is that the real problem lies with the insurance industry, followed by drug manufactures.
Now here my personal story, which I don’t believe for a moment is unique.
In my younger day, I risked a lot by not even carrying insurance.  I was blessed with great health.  As time went on I decided to get health coverage as a preventive process.  Two years after getting coverage, in 2003 I was under extreme stress, when to doctor to find out I had health issues.  My insurance rates were around 150.00 a month.  Today I am looking at needing make a decision whether I can any longer afford to keep paying.  My revised monthly premium from Anthem is $1060.00; $2,500.00 deductible; $5,000.00 a year co-insurance and a monthly injectable medication costing over $2,000 a month.  I have worked since I was 14 years old and have always been a hard worker, honest in all my personal and working relationships.
We are destroying the ethical drive of the private practice providers taking away their passion to conduct medicine.   It is truly a shame.  Unless you the patient were behind the scene, in the doctors shoe, be careful about your opinion.  Vicki

I have an other question, why must I pay 50cents per page to get copies of my medical records? I have offered to bring a scanner to their office and make my own since I can not afford to have copies made at the price they charge. They also charge to have records transferred to a new doctor…I can not afford the 2500 (or more) they’ll charge so any new doctor must re-do all testing as we start fresh versus seeing my records. In the military, they trusted me to hand carry my records but my current doctors won’t let me see my files unless I pay to have copies made for myself. This IS wrong.

$47/hr for your services is unacceptable? And you were free to quit and not look back? I really don’t see where you have a problem, other than a remarkable failure to grasp fairly simple economics. You made it through medical school, and this is your level of understanding? I guess specialization has its obvious penalties.
 
As the population ages, and demand for medical services increases, you’ll see more and more people entering the medical profession, and most of them won’t be MDs. Most will be MAs, nurses, and other staff who will be completely competent to serve the majority of the needs of patients. Meanwhile, you’ll still maintain your lofty perch above the masses, pontificating on macroeconomic matters that you don’t understand.

@Process2Succeed I agree!  People buy life insurance, car insurance, homeowners insurance (or not) and choose to live with the consequences should something happen that they don’t save for.  They also should expect to purchase health insurance or save up for expenses OR live with the consequences.  Is it a doctor’s fault that people choose to purchase iphones, ipads, big screen tvs, and on and on, instead of paying for insurance or saving their money for their healthcare OR even taking care of their bodies, by not smoking, not drinking to excess, exercising, and eating healthy?  People have a right to pursue their own happiness (even doctors).  Everyone has the right to work for whatever he or she wants (not everybody except doctors).  When people stop working for things themselves (ie reliance on the government dole) then they forfeit their rights.  Rights are things you are free to work for, for yourself.

Before you judge the doctor’s productivity – spend a day or 2 with 1. Not just the day, but the night – go for days without sleep and see what it is like. Then spend time with patients to be told off and receive $12 for the visit.
From a former Family Doctor.

I said “A billionaire may consider $500K chump change for heart surgery…” the point being while the rich can pay almost anything, the less fortunate have to worry about the TOTAL cost of health care. I agree, doctors fees are only one part of the total cost of health care. As best I can tell from causal conversations with friends, family, co-workers (I work for a hospital), etc., very few, if any, feel that their total health care costs are a good value. They indicated that health care expenses were frequently the cause of financial hardship, bankruptcy, etc.

@TheGoodPatient
Medicine is a bad business. Let’s say I provide anesthesia for a heart patient and get paid $250. 6 hours or work amounts to about $40/hour. Now if you pay taxes that cuts it in half to $125 or about $20 dollars an hour. Still reasonable you might say but couple that with $10 million malpractice claim that could hit me and my wife and you might say t hat doctors shouldn’t be afraid to make $20/ hr and risk losing $10 million, but I cannot. I don’t make $10 million and If I lose that amount I would have work like a slave my whole life to pay it off. This is a free country I am not slave. I have worked 23 years as a physician and will now quit to do something else where my financial risk is not so high. What kind of work do you do? Do you have a job opening for a risk adverse unemployed person?

Seems to me that you are what’s wrong with our healthcare industry. You strongly inferred that you would provide a lower level of service for services that you don’t make as much money on. I work in healthcare (on the IT side), and every time I run into a physician or care provider such as yourself, I become more cynical about the industry as a whole, since it’s very obvious that it’s not technology or money that’s standing in the way of quality healthcare – it’s folks like you.

This writer is wrong on so many levels, I cannot understand why he was given space on this forum.  This is irresponsible journalism.

@ShjhshjhI don’t like to call anyone a liar, but…
 
If you pay taxes on $250, and if that $250 is above the $250,000 threshold, the most you’ll pay in taxes is 35%, NOT 50%. And that’s only on the portion of your income that exceeds $250,000. Now, say that couple with the $10-million malpractice suit prevails in court. You don’t pay a penny of that award out of pocket; the insurance company that underwrites your malpractice insurance pays it (remember those high malpractice insurance premiums doctors are always bitching about? That’s what it’s for.)
 
What kind of work do I do? I’m in the health care field. I’m a massage therapist; I work half the week for a chiropractor for $18 an hour, and half the week in my own studio for anywhere from $40 – $150 an hour (before expenses). Except when I’m working pro bono for someone in pain who needs my skills but doesn’t have the money to pay. I’d say that’s about one-fourth of my private practice work, since many of my clients are referred by a DOM and a sole-practitioner community MD, who also do pro bono work because healing is the reason they’re in the field. If they (or I) chose our respective professions for the high income, we’d all be investment bankers.

Honey yes Dr Smith is legit. He speaks on behalf of many doctors that feel the same way.

Why be a physician (or in health care) if not to heal?  Am I missing something?  It could be that we have yet to change the paradigm from dis-ease care to true patient-centered health care.  If you really care about profits then address the patient experience.  Be efficient, caring, and empathetic rather than blaming and angry and see where you go.  Though the ingratitude of patients who may not take responsibility for their own health is frustrating, the level of fear and arrogance in this article is stunning.

I think that unless you have gone through medical training- working hard in college, 4 years of medical school and then at least 3 or 4 years of residency training working 100 plus hours a week and having no life outside of the hospital in the process, you are not qualified to make a comment that you have made.  I am not even mentioning hundreds of thousands of dollars in student loan debt.

@Scott Hill Try to pay off medical school loans on 47 an hour.

@RobertX  @Shjhshjh 
Taxes – as of 2013: (assuming the fiscal cliff hits – or they do not change the tax structure for high income people)
1) Medicare payroll  tax – goes from 0.9% to 2.35% on earned income over 200K
2) Medicare income tax – new tax – for high income earners – an additional 3.8% 
3) Bush tax cuts drop off – highest bracket goes from 35 to 39.6%.
 
So add it up = 35% goes to 39.6 + 1.45 + 3.8 = 45%.
 
So yes – technically Shjhshjh lied – he was off by 5%.  Except when you factor in his state tax – which I am guessing – is above 5%.  You have just hit 50%. 
 
Also – there isnt a single malpractice policy that covers 10 million dollars.  In fact – most policies cap at 1 million.  Unfortunately – juries have been awarding lottery tickets over multi million dollar cases – and in those cases – the individual physician’s own money/property is at risk.  
 
Its fantastic you do pro bono work.  Many physicians do as well.  Our group did some work in the community – but had to stop – since our malpractice coverage did not extend to the area we were treating.  Nice huh?  It is safer nowadays to go to a foreign country to do pro bono work than it is to do it right here in our own backyards.

@LMsmore  @SeattleNative57
 You forgot one thing, LMsmore.  Most doctors I know work 90 hours per week, so by the time you divide, some make at or below the average wage.  A neurologist friend of mine told me a few months ago that he worked 18 days straight.  “So what?” most would say.  But he’s not talking about 18-8 hour days.  He’s talking about 18-14+ hour days.  These folks are incredibly committed to work.  And we should appreciate them and pay them what they deserve.  Unfortunately, Obama thinks differently.

When the equation is about 500 to 1, I am sure that if Dr. Smith ever needs medical attention, he will find it very difficult for a NURSE, to care for a patient of his caliber.  I , as many of the many people who  have read this, wish people like him, simply look within and see if this really is what the medical profession is about.  As a retired California Nurse, I feel that if he ever needs care…I would give it to him for free…. and feel good about it.

Maybe you americans should learn from other countries. Here in The Netherlands we all pay a monthly fee for healthcare and in return theres a right for help if you need it. I work in a hospital and the doctors are paid very very well so there are systems that can work but some people are just afraid for change. Keep an open mind and don’t be arrgoant to say that things are different in your country. Open up and be willing to learn and change.

Mr. Smith likely worked very very hard to help save many people.
 
Question 1: Although not being paid very much, is it too little, and why does he need more (i.e. luxury or student-loan)?
 
2: Does he not agree it is great to have a government that pays him some money and provides hospitals/supplies to save many more people?
 
My conclusion: Mr. Smith, I think you did the right thing by taking it more easy and working a bit less hard.

@emdocarizona  Have I been asleep that long? Taxes as of 2012 (it is still 2012, isn’t it?): 35% for income above $250,000. My state income tax, like everyone else’s , is deductible from my federal income tax.

@jerryguzik17  Physicians are not the only ones who go through 4 years of college, 4 years of graduate school, several years of residency (though rarely if ever 3-4 years), working 100 plus hours weeks, not having a life the entire time, while accruing several hundred thousand dollars in student loan debt ….. and then come out with an earning potential 60-70% of a family practice physician… and a mere 20% of some subspecialties like neuro or cardio surgery.If you think doctors are financially stressed?  You have no idea what stress is.  Would you do all that med schooling if someone told you that your financial return on investment would be a $110K salary?  We all make the choices we made for different reasons… but none of them were with a gun pointed at us.  We made them willingly, knowing in advance the precise financial outcome.  We are stuck with the bad apples we chose, but we get some good apples as well… don’t forget that either.

I agree with RyanR. I left the US to attend medical school in Canada and after marrying a Canadian, I decided to stay in Canada to practice medicine. I see mostly poor people, some homeless 2 days aweek for substance abuse treatment. I am well compensated by the provincial government, and I had virtually no med school debt to repay because all Canadian Universities are public (quite cheap). The other days of the week I see a more uptown clientele on the Cancer Centre of a large teaching hospital. Again, well compensated (maybe not compared to my US peers).
Last year I was diagnosed with cancer myself. Even though I was between jobs at the time, my provincial healthcare picked up 100% of the tab for my surgical costs, doctor’s visits, scans and everything except outpatient medications (private insurance covered that).
When universal healthcare was intoduced in Canada, there was some blowback from physicians like Dr. Smith, but fortunately, the healthcare system went ahead and doctors who were only in it for the money were eventually replaced by physicians who were dedicated to healing.

Dr Smith has not understood the healthcare concept and fundamentally may be in the wrong job. Healthcare is not designed for Physicians wanting to make millions of money but to provide a service for a population that requires and is in need of healthcare. He also may not have paid any attention to healthcare in the State of Massachusetts or Germany where everybody has access and insurance and the system works just fine. Instead of healthcare insurance companies hat work on the concept to charge fees and decline coverage when ask to pay or hide behind pre-existing conditions, Obamacare brings accountability and should get rid of physicians that have an understanding of their patients as a Goldmine. We all work our hours and and every job is hard not only a physician. Frankly Medicine requires more than just to run a business otherwise we could have robots providing healthcare.

My God man just leave the profession. Threatening the population with ideas like”What kind of care do you think you will get”. Just awful. Everyone is entitled to healthcare. It should not be a privilege. The health of our nation is an important issue. If this is about the loss of the election. Shame on you. I would never come to you as a patient even with healthcare…….depending on how you are paid will depend on the treatment you would give me. Huh!

The big problem is that right now I know of only 1 primary care provider in our community that accepts new Medicaid, and the place is like a factory.  Why?  Because if you don’t run patients through as fast as possible, you go broke (for most billing codes, Medicaid reimburses less than the average cost of care).  ObamaCare is very likely to reimburse somewhere along the same lines of Medicaid if it is not just an expansion of the State Medicaid program.  Therefore, I agree with Dr. Smith — there won’t be many physicians lining up to treat patients at a loss. That is why ObamaCare was not healthcare “reform”, it just put more people into a broken system.  If it had addressed costs of medical devices, medications, medical education, malpractice insurance, etc. relative to these other systems in the world that supposedly give so much more “efficient care”, then costs could have possibly come down for everyone, ObamaCare or whatever type of insurance.  The end result WILL be all these new ObamaCare cardholders showing up at your local ERs and flooding the place with primary care needs because this is the only place that cannot turn them away due to the federal EMTALA law.  That cost strain on ERs will likely amplify the trend of ER closings around the country (esp. in urban inner city areas), thus further stressing the remaining ERs. Wait times in ERs will climb, making everyone unhappy in our “me and now” society.  Those with true emergencies will be more likely to wait longer and have a worse outcome as a result (more lawsuits).  In times of disaster, an overcrowded “emergency” system has less capacity to respond to that bus accident, terrorist attack, etc.
 
As a side note, what is really driving the cost of American healthcare is our obesity and how it complicates and causes all types of disease (look it up — we are second only to Pacific Islanders and one other island in the Bahamas I think in BMI).

@Scott Hill Really Scott??  Last plumber that came to my house charged $95/hr, and you think that Dr. Smith should accept $47/hr after all the years it took him to become a board-certified anesthesiologist.  Plus, how often do you see plumbers get sued for their entire net worth if your pipe leaks?

Brilliant an to the point Dr. Smith. If people do not get this, then we really deserve the governments we elect!

The only problem is that healthcare is not like an Obama phone.   
And this is where I stopped reading.  This is crap and the author should be ashamed for this childish right wing meme.  If you want to make a serious point, don’t start with Fox News talking points.  The rest of your editorial is tainted by your inability to write without taking pot shots.
I work in the IT department for a large practice and I say all the time that all those years at school and doctors can still be such morons.  Thanks for proving my point.

@Healthcarerealist Where is the patient’s responsibilty in your payment scheme? The physician is assuming the risk of not being paid because of a noncompliant patient. If we bend over and take it and old Joe won’t comply, I’m being punished and Joe is not any healthier….maybe Joe needs to be penalized too. Oh yeah, then old Joe can sue my butt off too because I didn’t emphasize his problem enough obviously because he didn’t comply. You know what, people are going to get sick and die eventually. We need to be paid from the patient, then maybe the patient will take care of themselves.

@Kevin Szyskowski RPh Really? let’s try it at your place of employment….you need to give this to me free because I can’t or won’t pay and I have the right to your service for free….this my friend is slavery. I’m sure lots of young men and women will want to go into medicine.

If doctors had been more proactive in trying to help control health care costs, maybe Obama care would never have been necessary.  I got tired of footing the bill for your million dollar houses and cars, especially with the specialists.  It seems to me one way or another I’m footing the bill for an overpriced delivery system.  And if all you care about is how much your getting paid, I don’t want you working on me anyway.

@emdocarizona @GShelton Amen!

@Kevin Szyskowski RPh, EMTALA (Emergency Medical Treatment and Labor Act) does not guarantee anyone care unless you are very ill! It is simply a guarantee that you will be seen by “a qualified medical provider” and receive a medical screening exam to determine that you are not “unstable”. It then assures that you receive “stabilization”. That is all it guarantees. Under EMTALA, the hospital and doctor have the right to evaluate you and determine that you are not dying eminently and then refuse to care for you until you pay for your healthcare. That will do nothing for primary care/ diabetes management/ nutritional education and most of the routine care that everyone needs. If you are talking about forcing all medical practitioners to care for everyone who shows up at their office regardless of their ability to pay, that is a completely different mandate than EMTALA. Perhaps, since food and shelter is a “right”, if a homeless person shows up at your door, you should be required to feed and house them. After all, they could die from exposure and starvation if you do not step up and meet their demand.

After being in the business of health care over fifty years, I can see one way that obamacare might be helpful. Outlandish law suits would not stand a chance. No lawyer will want to sue the government for the kind of care they have imposed on a person they have accepted as a client.

Lot’s of kool-aid drinkers here slamming the good Dr, who is simply pointing out BASIC ECONOMICS.
 Said another way, who posting here works for free?  Who is going to go out tomorrow (assuming they’re presently employed) and find a new job for less money, that doesn’t cover their expenses, in order to feel good?  Answer: only somebody who is on the government dole (i.e. living off of taxpayer money.)
 By the way, your patron saint Steve Jobs didn’t build your iPhone out of a sense of philanthropy … and Starbucks doesn’t fill your mug out of a sense of goodness.

@Skepticscalpel seems kind of bitter

How is your described ObamaCare Accountable Care Organization any different than existing managed care companies?  You might want to consider working for one – - they share your philosophy of denying healthcare to as many as they can get away with.  Rather than fighting it tooth and nail, why not acknowledge that universal single payer healthcare is working (albeit far from perfectly) in most other developed countries – - far better than our own current system.  Why not analyze their strategies, learn from their mistakes, and design something even better for ourselves!  Why should the American consumer pay all the R&D costs of drugs that are sold overseas for a fraction of our cost?  As just one example: if we eliminate the lobbyists that prohibit Medicare from negotiating for lower drug prices – - which managed care companies are allowed to do – - we could afford higher reimbursement rates for providers.

the only thing better than this editorial, is the comments section flowing over with accusatory and insulting dross from the exact type of entitled little children that have caused the issues the writer laid out. here’s a hint folks: if someone has to provide it, it’s not a “right”, and using FORCE to obtain that provision is nothing short of enslavement.

@GShelton , see the discussion above about physician payment. It is set by CMS (a.k.a Medicare) and the insurance companies, not by the physicians. The biggest problem with healthcare is that the patients are only exposed to the true cost of their care AFTER it is received. 
Transparency (the new government mantra that really does not apply to themselves) would be a great starting point. Very rarely do people “shop” for their healthcare. They show up at your office because you are on the list of participating providers and Mr Smith from Bingo thinks they are a good doctor. 
When was the last time a patient actually looked at the cost of Dr X and compared it to Dr Y? Or the quality of care of Dr X vs Dr Y? If people will shop for their healthcare like they do a refrigerator or a car, the costs would go down and the quality of care and the delivery of care would go improve significantly. It’s called capitalism. Look it up. It works. 
Right now, healthcare is a system that many people walk through blindly and then wonder why they walked off a cliff. This is EVERYONE’S fault: Providers, insurance companies, Medicare, hospitals, AND patients. The ACA is not the answer. 
Please tell me which government/ hybrid program you want to model you healthcare after: 
1. The US Postal Service 
2. The Veterans Administration (what is coming for all patients) 
3. Amtrack 
4. Fannie Mae or FreddieMac

@eaglesfanintn You sir have revealed your own ignorance and bitterness. The rest of the article makes a good point…why should a doctor be forced to lose money on seeing a patient? Doctors went to school longer than you did for IT.

@Sheri Young I think you have failed to recognize the import of your comment…No one is forcing you to be treated by any physician at all, and if a world without medicine is better for you, then so be it. Doctors have spent decades in training so they can help you understand your complex body systems and how to regulate them. They live for years with little to no income for the work they put in and take on more debt than most people do for their home. They need the high income to pay off the high debt.
Additionally, they sacrifice in school. They sacrifice after school. All to keep you healthy. Working 80 hour weeks…letting patients call in the middle of the night and wake them up. Doctors are undercompensated if anything.

@kidneykim This isn’t a threat. It is a reality. Think about it…if a doctor needs to make a certain amount of money in order to be profitable, he can spend less time with a patient if he is paid less.
My dentist told me essentially the same thing. He gives better care to patient’s who have insurance that pay more because he can afford more time with them.
This is no threat. It is reality.

@jkriegel8 Interesting points, but they fall short of the complete picture. They overlook the extreme costs physicians face in the form of insurance against malpractice, debt payments, staff costs (docs can only bill for their work, but have to pay the whole staff), rent, etc. It isn’t cheap just to stay in business….don’t think the doc takes home much of what you see in the final bill.

@Madeline Oconnor But funding it is the issue…essentially this is making everyone pay for those in the US who do not wish to put in the work and dedication to achieve a stronger financial condition. Certainly there are those in our society who we should cover as a group because they genuinely can’t, but many times capable people forgo education or the opportunity to work and achieve paying for their own life. As a country we need to wake up and realize that we have the responsibility to pay for our own lives, not depend on the government to take care of feeding and clothing us.

@Healthcarerealist @jerryguzik17 Name one career that goes through the same length of training?

@Narayanachar Murali I believe the problem lies in the fact that we “people” do get this. In my job, I work for my clients and hope I get paid. I almost always get paid. If someone doesn’t pay the agreed amount then I can choose to still work for them if I feel they need the service, but can’t afford it. Doctor’s have the same rights. Dr. Smith is stating he is giving up his profession because he thinks poor and elderly people should know better than to get government assistance when its offered to them. He also implies his patients shouldn’t get upset when medical treatment is refused. He doesn’t like the government programs (and apparently the patients). I agree that he should leave the profession because frankly, if he doesn’t like the current government programs he won’t like any of them if it means giving up his lifestyle. However, he will now need to go back to school to become a lawyer, banker or politician to keep it up. Perhaps blogging is now his thing.

@jkriegel8
Health care in mass only works due to giant federal subsidies to keep the system afloat. European nations ration care like you would not believe and would likely find unacceptable forcing patients into clinical trials.
The point that the author is trying to make is that right now government healthcare pays below the cost of doing service, and that many doctors find this unacceptable, as would most rational people. If it takes 100$/hr to stay open but you are only paid 80, you close. You might say it is that the overhead is too high due to inefficiency etc.., however when everything is mandated and forced upon you there is no way to controll cost of overhead.

@MrsMart  @Kevin 
The difference is, at my place of employment, if I deny someone service because they can’t or won’t pay, it is not going to threaten their life.

Quality of healthcare delivery is not a quantifiable process due to the many variations in presentation, it is a fluid process, especially in the cognitive fields. How about putting a financial limit on your healthcare if you wish to start quantifying your value to society? How about a limitation to the numbers of hours available for your healthcare needs? How about demanding to have a perfect weight/body index and a forced regimented diet (per government – ala Solent Green), perfect blood pressures – oh but those pesky genes get in the way of everyone being the same

Thanks for telling it like it is.  Having health insurance is not the same as having health care.  Based on the majority of comments on this board, sadly, the government has done an excellent job in demonizing doctors so the public wrongfully views them as the problem and not the solution.

@Scott Hill He didn’t quit and not look back….he quit that part of his practice to concentrate on the more lucrative part. Why should he do something that pays him less if he doesn’t want to. That is the whole point of the article.
Also, remember he still has to pay malpractice, and support staff costs etc with that $47/hour.

@Kevin Szyskowski RPh Wow.  That one just boggles my mind.  How a pharmacist could come up with such a RIDICULOUS idea scare me!  Don’t you realize that ER’s invariable LOSE money for the hospital, despite their exorbitant charges?  Hospitals are only able to make up those losses through the other (high-priced) services they provide such as surgery and imaging.  Imagine a family doctor’s office being FORCED to see everyone who walked through the door, even if they had no intention of paying them (surely you don’t think everything will be “free” to the patient, even under Obamacare).  How long do you think ANY doctor’s office would stay open?

@Fireinthewhole While I definitely sympethize with your point, think about it from their perspective…The medical file is to protect them from a malpractice suit. If they let you scan it, you could potentially (not that you would, but they have to think this way), destroy a key part of the file. Why do they charge to copy? Because they have to cover the cost of the toner, the copier, the the person to make the copies, the cost to send the fax etc. 50 cents a page is probably too much, but I don’t think it is unfair for them to require you to pay for the records since it costs them money to share them with you. Hopefully, as EMR’s become more standard, you will be able to eliminate this cost entirely.

@kidneykim Would you continue to own a business that your overhead costs more than what you are paid by your clients?  Say you are shining shoes and the cost of supplies per shoe is $2, but suddenly the price jumps to $5 but your customers set your pricing and will only pay $2.50/ shoe.  How long could you stay in business?  That is the reality of medical practice today.  Someone else is setting the fees for physicians (the government and insurance companies) but the suppliers of what is needed to practice is set by someone else ( medical suppliers, pharmaceutical companies and the government) and the current situation is that the cost of supplies is greater than the reimbursement.because the cost of supplies continues to increase and reimbursement continues to decrease.  Physicians are not allowed to bill patients anything over what the insurance company pays or the government pays and the reimbursement has decreased to about 20% of what it was in 1990.  Do you accept continuous pay cuts are now working for 20% of what you made in 1990?  I didn’t think so.

The problem is, Americans don’t want to pay anything for anything.  Since they view healthcare as a right, they expect it to be free, not for a monthly fee.

@VickiH Excellent thoughts. In addition, as you take away that motivation for the providers, the providers will quit, increasing demand, and based on standard economics, increasing the price…exactly the opposite of what so many people want here.

Would you stay in a business that you were paid less and less every year?  Would you continue in a business if you were losing money in it?  Why are you opposed to physicians supporting themselves and their families?  None of us are going to be millionaires, but our salary is now at 20% of what it was in 1990 and for primary care physicians, most are making well under $100,000,

The problem remains that we still don’t know what “healthcare” is let alone Obamacare. Patient – give off the couch and heal thyself (and my wallet).

@DonW Physicians don’t get paid $500k for anything.  The most a surgeon will make for any surgery regardless of complexity is about $5K and for women’s healthcare it is $1500 for the same 8 hours of work that previously was reimbursed at $15,000 ( major tumor reductive surgery for gyn malignancies) .  Hospital expenses have skyrocketed and there is little effort to control that part of the equation but physicians are now making about 20% of what they made prior to 1990.

@mikewhawkins Yes, it’s true, no easy answers. Here is a doc’s perspective from the same discussion ^[9] #healthcare #jobs

@Sheri Young if people would be responsible for their own health by exercising, eating right, not smoking, and actually going to see their primary doctor annually, their health would be better. I didn’t realize that doctors need to go to people’s houses and drag then kicking and screaming to the office!

@VickiH You nailed it Vicki! The pharmaceutical companies and health insurance companies are destroying healthcare.  Massachusetts universal healthcare showed that $0.12 of each dollar spent actually paid for healthcare and the rest went to administrative costs.  Eliminate 3rd party payers and regulate costs of pharmaceuticals and healthcare suddenly becomes more affordable, if you can find anyone willing to participate as a healthcare provider.

@Sheri So @Doc in Training  is saying that people that have spent decades in training so they can help you understand your complex body and live for years with little to no income for the work they put in should be able to live the high life? Did you hear that single moms? In that case every hard-working chef or mine worker should get these rewards. The statement “They need the high income to pay off the high debt” is the worst argument in the world.

@holmesmd1 well said and to that I think that most of the folks here who are so anti-doctor fail to understand the skill set required to be a physician. The same folks on here would have no problem glorifying a football or basketball player for playing a game! Priorities are screwed up these days! Honor and respect achievement and pay those who provide specialized services! Not everyone can write computer code but you’ll bet you’ll pay for competent people to do the job for you! Yes a plumber does cost 95/h and no one complains because when your up to your knees in sewer water, you tend not to argue much! Medicine is like any other industry good medicine should be rewarded and bad medicine should not be. But making doctors out to be greedy rich folks is nuts…look at the doctors parking lot these days and you’ll see Hondas and Toyotas not BMW’s or Mercedes!! And that’s too bad because most people who go into medicine didn’t do it to be millionaires but did it to have a better than average life and they deserve that for the time effort and work that was put in!
Next time you need a doctor ask yourself should I ask for the $20/h doc? Good luck with that!
People need to understand the true economy that physicians live in…we have astronomical costs an have no control over what we get paid!! Great life huh??

@Brotherskeeper which profession requires the level of training that medical professions have??? Please name one???

Where is the largest percentage of healthcare expenditures generated? End of life care. If you want control costs, stop spending tens or hundreds of thousands of dollars on every patient who is at end of life. If you (or me) are 80 years old and lying in a bed in a nursing home, unable to walk, unable to live, you should be made comfortable and treated with compassion, but not put on a ventilator in the ICU, on antibiotics that cost $1000 per dose, and aggressively resuscitated when your heart stops! THAT will save money and free up resources for others who are able to be improved. But most people dot want to contemplate that for their family. Again, ok for Mr Smith down the street, but not Grandma or your spouse.

@eaglesfanintn Obviously there are differences in opinion on the broader question here, but I would like to focus on the post by eaglesfanintn.  You call out the OP’s statement as “childish” yet use an utterly vapid, naive and illegitimate debate tactic – stating that just because an issue is a “Fox News talking point” it is categorically wrong, immaterial and not worth discussing, without examination.  That sort of absolute “tribal” prejudice is far more indicative of poor thinking and a weak position than an arguably weak simile and stretch of applicability on Dr. Smith’s part.

@Doc in Training This is why I offered to bring in my own scanner to do it at their office. Over the years, I’ve made the mistake of bringing peer reviewed medical articles related to my medical condition to my GP…which they did not read but did put in my medical file which is now hundreds of pages. I’ve asked that copies be made of only medical notes and tests but their office will not sort out irrelevant data. So I must pay for copies of all or none…it is like being held financially hostage. Each time my insurance changes and I must change doctors or pay out of network fees, my new doctor doesn’t get copies of anything because my current GP only gave me haphazard copies of test results. As for electronic health records, as is fair, the new doctors using them charge to scan old records into them. Ergo, I’d rather have the files be mine and I share them. Honestly, as for suing a doctor, which one would you sue? The one that forgot to run a test? The one that didn’t talk to the other one? The one that did an irrelevant test? Or the one that dismissed your concerns about medication side effects or symptoms? You’d have to sue them all to be fair…becuase you’d never be able to prove which one had the most responcibility. I mean technically, I have the greatest responcibility for what goes wrong in my body therefore I need the information they have. I have zero interest in suing but I do have an interest in avoiding medications that are damaging. My doctor may know more about medicine but I know more about my body and in my opinion this makes us pretty close to being equals. I would never sue someone that treated me with empathy, competence, and respect. Doctors need charm school more than they need tort reform.

Nobody is forcing you guys to become a physician but if you are not willing to carry out the job with dedication, get out of it. Society pays for your schooling too and most physicians do not earn badly in comparison to the average income in this country. When you are not willing to put in the hours and the dedication do something else. Medicine is more than a job and requires more than just the look at the bankbook. The problem are the for profit insurance companies that can in the case of Harvard Pilgrim pay more than 2 Million to an CEO. We do not need private healthcare companies, we need universal healthcare with a single payor system. Make the physician employed by the hospitals and work for a salary and if they are showing an attitude like the author, fire them.

@RobertX  @Shjhshjh
 No malpractice policy covers a $10 million judgement. Most policies have limits of about a million per occurance, some less. The rest is out of the doc’s pocket. While I appreciate your dedication as a massage therapist, you did not spend 12-16 years training to do your job, incur $200K in student loan debt, run an office with multiple highly trained employees (who epect to be well compensated for their expertise), pay malpractice insurance premiums that can run $150K/year, be available for emergencies 24/7/nights/weekends/holidays, “invest” in fancy government-mandated  computer systems costing hundreds of thousands of dollars, and despite all this have no right to set your fees to cover your business expenses while you watch your earnings drop every year. Do you make the same or less now than you did 25 years ago? At some point, it really is all about the money. You can only be abused for so long. If the gov legislated that no massage could cost more than $5/hr, would you start looking for other opportunities or would you continue to plug away and hope that your customers’ gratitude will help you get by?

@Erdrfl  That’s not what she said at all. Everyone here agrees that people should take care of themselves. You’re way off topic.

Bottom line, no doctors no healthcare. You cannot force anyone to spend 12 years minimum training in premed, med school then residency, if he can make the grades and endure the schedule, to be competent to practice medicine. There are huge disincentives to go to medical school now. I have practiced medicine for 22 years and I love my patients and do not regret my decision to be a doctor. You do not get rich being a doctor ( should have been a college football coach or a movie star). Although my son has the intelligence, the temperament and the work ethic to be an excellent physician, I am not encouraging him to choose medicine in this litigious and political climate that treats physicians with disdain. So easy to criticize when you have not walked in the shoes of an exhausted intern. Most physicians I know now do not want their children to choose medicine now. Just the facts. Think about it before you get sick and need the expertise only an experienced physician provides.

@Works with doctors  @Narayanachar Murali Choice is the key point to your argument, you can choose not to service any client of yours that is not willing to pay for the services at what rate you have determined. For physicians, if you decide not to play with the government or insurance company and become low-balled, then you are labeled as selfish, greedy, uncaring for the will of the people, but in any other business (especially lawyers or bankers but almost any other business) this is considered to be doing a good and profitable business plan. Dr. Smith is completely right, and you know this. It is not that he cannot or is unwilling to continue practicing medicine with compassion and vigor, it’s the desire to continue to make a relatively appropriate amount of money and live a lifestyle commensurate to his level of expertise and training and hassle for practicing medicine. The public has no idea what these government intrusions cost to a private or even employed physician (hospital controlled reimbursements to physicians are going down, people as well as higher overhead is passed onto the physician’s earnings). Many details that the average public Joe has no clue about, but yet they continue to think that by drinking the political, especially Obama, koolaid of dirty, greedy uncarring physicians will make a good mantra to entice physicians to stay and serve their greedy selfish needs as slaves. Grow up people.

@eaglesfanintn So if one of those Doctors asked you to make a diagnosis, are you saying that you can do just as good of a job?  I dont think so, unless you’ve somehow mastered medicine through osmosis.  
 
You seem to value your own abilities as a IT manager.   ie:  you label doctors as morons probably because they have difficulty with seemingly simple computer problems.  To you this is an easy task. But you are a specialist who is trained to do this and you are paid for that expertise.  Are you not?  Doesn’t this job that you have pay better than a job flipping burgers?  OK then?  
 
What you fail to see that you are making the same argument that author is.  Dont be distracted by the rhetoric.  
 
Lets go through a hypothetical situation:
Suppose for a second the “Moronic” doctors walked into the office one day and said hey “eaglesfanintn”  we are required to have an Electronic Medical Record by the government.  Since you are the IT guy its your job to maintain it.  But we as physicians feel that up to this point you have been way, waaaaay overpaid.  After all, you just sit there and type at a desk all day ……and probably spend half that day on facebook and surfing the internet ….. oh and posting comments to blogs about healthcare …. when you should be fixing our problems….  Anyway ”eaglesfanintn”  we’ve decided that you should be paid half  the salary that you are collecting … for now  ….. and next year probably less than that.  Cool?  I know this sounds terrible but we “Moronic” doctors around this country have gotten together and passed legislation to make sure that you have to accept this salary, no matter what, because we must have an National Electronic Medical record.   Three cheers for the “Morons” , hooray!   So “eaglesfanintn”,  all that your experience that you have, its pretty much going to command the same price no matter what part of the country your’re in, and no matter how good you are at your job.  Here is your future.  Its not very bright, its not based on how good you are, and you cant negotiate the price.  Now get to work.  We’re entitled to it.
 
 
So what do you think?  This is the situation in medicine.

@jkriegel8 No one has to do anything they do not want to do. If you did not read the article completely then you missed that he quit thus being his option to opt out of the field. Also society does not always pay for someone schooling. There are many people that pay for it themselves so don’t assume that is the case for everyone. If you pay doctors a salary fine but they will take that salary on their terms or work somewhere else.  Also when the incoming revenue is not as high as the cost of running a hospital due to the gov. decreasing what it will pay then you have no hospital or clinic. Everyone wants something for free but doesn’t understand that someone somewhere is paying for it and when that person paying for it can’t anymore you end up with a whole lot of nothing.

@Healthcarerealist  @jerryguzik17 Could you give me an example of professions that you described in your paragraph. 
I have friends/family who are attorneys, investment bankers, traders, small business owners, accountants, college professors, and some of them make more money than an average physician and some of them make less, but none of them comes even half way in their educational experience compared to an average physician.

@jkriegel8 Get used to lower quality care and less access to it.

@Erdrfl So you want death panels? Assisted suicides? What is going to end that problem. People make their own end of life choices or the family does if they cannot. You cannot take someone’s right to live away from them. That is not yours or anyone other than the individuals decision to make.

@Fireinthewhole  @Doc The moment any one presents with: I know my body better than anyone else, they are granted an automatic pass on to someone else to care for them because they really don’t have a clue and are already predestined to failure in the eyes of professionals. Again, you make massive demands on caretakers time to read Dr. Google nonsense that they don’t need to keep in the expensive medical records (either electronic or otherwise). By changing caretakers so frequently, you generate errors and miscommunications on all fronts – the fault does not lie in the system but in you and definitely not with your physicians.

@Works with doctors  @Narayanachar Murali you work with doctors but you are not one, you did not spend the amount of time they did learning and suffering through the bad times. To be reduced to being paid $285 for a 6 hour surgery is an insult to to people that have taken the time to learn all they need to so that person in surgery is safe.  If you do not agree with the regulations and you job is not enjoyable for you anymore you quit and that is what he did. He has ever right to make that choice and did it with his patients thoughts in mind because he know he would not be doing them any good not wanting to be there.

Dr. Smith, I agree with most of what you had to say. But I have another concern. You said that if too many doctors quit, the government might try to make then work. One of your respondants said that many doctors will be replaced by less expensive persons such as MA’s and nurses. In other industries American workers have been replaced by workers in other countries for a myriad of reasons. For at least 30 years foreign doctors have come to the U.S., gotten American training and worked here, replacing or supplementing the American workforce. What I think will happen as the demand increases and the pressure to reduce costs also increases is that the number of physician extenders (PA’s, NP’s, MA’s, RN’s, LPN’s, CRNA’s, and AA’s) will greatly increase. We already see that happening. But here’s where I make another even bolder prediction. I believe that many physician responsibilities (e.g. radiology, pathology, anesthesiology) will be performed by physicians electronically beyond our borders. In addition to that I believe we will see a large number of physicians and physician extenders from other countries allowed to practice medicine in this country with little or no American training. In other words the American residency requirement will be waived or terminated. What effects these changes will have on quality, cost, or litigation I am less certain. These changes might also occur so slowly that we won’t feel the pain of their impact nor be fully able to recall “the way it used to be”. I also believe the inevitability of these changes go way beyond the ability of either political party to avoid them.

If you are not making enough to support a family and live off of but have to work the amount of hours doctors do why would you want to stay or be able to for that matter. On top of that as he stated the people on gov plan are the most demanding and ungrateful. It pretty much kills the passion you had for healing when the ones you are healing show no gratitude at all.

@Fireinthewhole  @Process2Succeed And how does the CEO of your local bank discount your lending rates? How can you have different set of standards between business and healthcare. A unique set of skills allows the setting of their price, an IT tech costs between $150-250 per hour in our area, most primary care physicians or cognitive specialist can only charge a fraction of this because the payments are already set by the government and insurance industries. How do you think this new overflow of low paying exchange patients are going to be taken care of? There are only so many days and hours that can be worked, only so many people can be seen per hour safely, where do you really think they will get their care – well, obviously in the ER. How many of these low paying patients are going to get into a doctor’s office each day? Maybe one or two if they are lucky – it is now about a balance between taking in money vs taking more time off for less money and seeing less patients. Physicians owe nothing, they already gave at the office.

Can a physicians provide major health care services without a hospital? If the doctor depends on services provided by a hospital, then he/she should care a great deal about the price the hospital charges, because it ultimately affects his/her business. In other words, if the patient can’t afford the hospital bill, it does not matter what the doctor’s bill is.

@Healthcarerealist  @jerryguzik17 They made these choices based on a set of standards at the time. Its like changing the rules in the middle of the game and calling that fair play.  Many doctors will simply quit which is the point. All of the sacrifice and hard work reaps them no rewards to support a family so why stay in a job that will not support you finacially after all that hard work?

@PetePetePete
 Interesting points, Pete(x3).  One thing you can guarantee:  If Obama brings in help from foreign countries to prop up his floundering healthcare system, he would exempt THEM from lawsuits.  After all, they’re just trying to help.

@Sheri Young
Sheri- The overpriced delivery system is primarily the responsibility of GOVERNMENT REGULATION AND INTERFERENCE.

Most of the uninformed and hostiles responses to Dr. Smith can be summed up Milton Friedman’s principles.
 The people who derive their benefit when the cost is born by some one else they feel entitled and spend/utilize more leading to the spiraling costs.
 ”There are four ways in which you can spend money.
 You can spend your own money on yourself. When you do that, why then you really watch out what you’re doing, and you try to get the most for your money.
 Then you can spend your own money on somebody else. For example, I buy a birthday present for someone. Well, then I’m not so careful about the content of the present, but I’m very careful about the cost.
 Then, I can spend somebody else’s money on myself. And if I spend somebody else’s money on myself, then I’m sure going to have a good lunch!
Finally, I can spend somebody else’s money on somebody else. And if I spend somebody else’s money on somebody else, I’m not concerned about how much it is, and I’m not concerned about what I get. And that’s government.”
The entitlement mindset reflects the mismatch between who ( service/behavior ) is costing and who the (service/behavior ) is benefiting.
If benefits and costs are not both shared to some degree, we will have potentially troublesome motives!~outcomes
If it is my resource( Time, Effort, Money, property ) I am more likely to protect it.  If it is some one else’s resource, I am less likely to protect( value) it
 Ownership of the Cost and Benefit ~ Powerful Motive.
 http://www.youtube.com/watch?v=-MQp-5lZToE
 If doctors want to become millionaires no one will enter the field anymore and will find ways to get out of the field. It’s the compassion and satisfaction is what motivates.
 Hourly wage of many physicians are less than Plumbers & over priced IT workers.

@matt great thought!! You actually speak from a common sense point of view… If your costs are higher then charge more..simple economics….BUT that’s not the way it works!! I can charge 1000$ but I’ll only get what some monkey in a cubicle tells me my work is worth…peanuts!!

@jkriegel8
Your ideas are basically communistic. If u want to take away all the incentives and let the government run everything go to a communist country and see how u will like their healthcare system.

@Kevin Szyskowski RPh Ok, I was staying out of the conversation until this ridiculous post. Extend EMTALA to all individual solo practice physicians? So you are going to support a law that tells me I have to see a patient who refuses to pay, refuses to take care of themselves, refuses to comply with simple and basic tenants of health and wants to blame me for their self-induced medical conditions all while my clinic struggles to make payroll and rent? Really? You want to pass a law  that requires a business to stay in business even when they are losing money? Really? Will the government bail me out when my clinic goes under because I cannot pay the bills due to patients not paying or insurance not covering costs? Really? You want to enslave me to our poor health care system that supports waiting until a person gets sick before we take care of them? Is that your right to impose upon me a system that is slowly killing my clinic.? , the physician. Wow. I am restraining here…..

@MrsMart  @Kevin You exaggerate MadHamish. That is what the ER is for and what EMTALA covers. Life threatening situations. Mr Szyskowski is talking about a blanket law to make ALL physicians stay in practice and see anyone who walks through their doors.

You just described the results of the current failed system… That we are now going to dump 38 million more people into…..with fewer doctors…..more work…..do you see what is happening now? Imagine how much more worse it will get forcing more patients into a failed system .

Specify….spend it with a primary care doctor, gyne, Ob who take medicaid/medicare…

@DeejayAustin  @eaglesfanintn
@DeejayAustin “vapid, naive and illegitimate”??   Yet…”Fox News talking point”??  I’d call that poisoning the well.  Check your logic/debate notes.

There is obviously no forethought in the political solutions to the problems faced in healthcare. First: the government is the problem. They allow themselves to regulate more than the cost of per patient care but also inducted severe penalties for unfunded mandates and restrictions to practice medicine (EMR, fines for time limits and usage of testing). Two: Government allows insurance companies to gouge their clients on policy costs yearly and restrict treatment options without logical or medical evidence as well. Three: the pharmaceutical companies have been allowed to gouge the cost of medications to extraordinary heights and pharmacies to increase their profits at the patient’s  expense. Four: the Medicare and Medicaid cuts and the low ball prices of the exchanges will lead to a marked reduction of payment rates by private insurance companies – all of these are essentially non-negotiable, it’s an all in or all out proposition in which if chosen to be out, it is a cash only or concierge practice. Five: the false premise of bringing in as many foreign physicians, nurses and other para-medical individuals to fill the gap is just plain stupid – they come here to earn a better income and that is not achievable for very long on the current planned pay schedules. Six: healthcare is not a right – it is like buying any other thing (car, house) those with the money get the Rolls or Ferrari, the rest will have to do with “the peoples car”, the more you spend of your own money the better you take care of t.hat car or house. The people’s car individuals won’t even change the oil or a flat tire. Best of luck finding a physician in the near future, yo will have to do with lesser experienced caretakers, many shortcuts fraught with misdiagnosis and less than optimal treatments dictated by some non-entity ill-educated government highschool GED’ ed employtee – yes all of those medical treatment decisions will be determined by a central committee on real time phone calls at the time of visit per Obummercare decree. We should all start moving to Colorado, I never did any off that while growing up because I was too busy studying to become something much more important,what a big dummy, huh?

HC Truth: What is your malpractice insurance cost and risk?

@Works with doctors  @Narayanachar Murali If you read this carefully you’d know that Dr. Smith did not quit being a doctor.  He quit doing a certain procedure and he quit accepting certain patients.  He said that, “the angriest patients I’ve ever encountered were the Medicare patients I subsequently treated with no charge whatsoever. My providing charitable care elicited patient rage like none I’ve encountered since.”  I can believe it too.  I’ve been in many hospitals waiting for care with my special needs child.  And a lot of patients who get Medicaid are very demanding and angry.  Why would doctor’s want to treat patients who act that way?  Especially when getting paid for Medicaid is pennies on the dollar for a doctor.  Their practices can’t make it with those payments.  I had a friend in private practice who went out of business because he couldn’t pay his office bills and he wasn’t taking a big salary.  If I were a doctor, I’d take patients who treated me with respect – and the rest could find someone else to treat them.

@Doc in Training  @kidneykim Exactly!

@guest159 The other thing is that Obamacare adds another level of administration fees.  It’s not going to get cheaper, it’s going to get more expensive to run healthcare.  And because of the actual medicaid reimbursements being so low, a lot of medicaid/medicare patients aren’t able to see doctors now, many only can see a PA.  And while their training is often exceptional, they don’t have all the training and knowledge of the doctor.

My grandson was born in The Netherlands four weeks ago. My son is American and my daughter-in-law is Dutch. She was to deliver in a “baby hotel” with a midwife in attendance, but after more than 30 hours of complications was sent to a hospital. They could not admit her because there was no room. My son drove her to another hospital who gave her morphine. She was then sent to another hospital because by then it was clear that there were complications. Finally she was given an epidural, but when the doctor began the C section they realized that she had complete feeling.
In another horror story, son had a cyst on the side of face. (He pays for private insurance.) It took him more than a week to get an appointment, despite the fact that he couldn’t open his mouth due to pain. The doctor told him it would improve over time and gave him some ointment. A few days later he was in such pain that he did what Europeans have learned to do–go to the emergency room and demand treatment. The performed emergency surgery.
Don’t promote the outstanding health care in other countries. Access is universal if they can work you in, and while there are certainly many outstanding health care providers in The Netherlands and other countries with socialized health care, most of the time you get what you pay for.

@jkriegel8 how does society pay for my medical school tuition?

@jkriegel8 ”Make the physician an employed…..fire them…..”  Wow. Is there anyone else reading this crap think that mandating a physician to practice insurance medicine, take away independent and critical thinking and place it in the hands of insurance driven treatment protocols and factory-like patient care is the way to go then you are asking for a more diseased driven care system that rewards minimal thought process. Is that the care you are asking for? Would love to hear your answer. Think through what you said: In one sentence you stated logically that Medicine is more than just a job…..then in the last sentence you said…give all thedoctors a job….  As a physician I do not have a job, I have a simple calling and responsibility of improving an individual’s health AND the overall society’s health. You want to employ me and fire me if my attitude is not to your liking? Who judges that? An attorney? An insurance administrator? I certainly get calls from each of them telling me I do not practice medicine to their liking on a weekly basis. Well, the current trends in this country are doing just that: Firing me, the primary care physician.

@jkriegel8 There is no excuse for being ill informed. Physicians choose the profession for a sense of challenge and demonstrate great dedication to the education, training and performance of medical practice – much more than any other profession. Society does not in any way pay for the majority of physicians to become educated, unlike the President Obama and his wife who did it all on public money. Talk about letting more foreigners into federal government.  Any way, as with any human, there is a strong desire to be amply compensated for your above average talent and efforts (long hours, greatest risks of any business, past debts, etc). There is a very common misconception that physicians are of average,  regular people – with an average intelligence and the low typical ambition of the rest of society. Well, they are not. They represent the top 2% of intellectuals, and mostly are the type A personality that drives them to accelerate to the top- which is also the reason patients despise the “bed side” manners of these type people, they cannot be that gummy personality of the public demand (not even asking anymore). For what has been paid over the past twenty years, the public has gotten more than they deserve for their dollar and when the dollars begin to decline, expect less for your currency (called devaluation) and lots of less time spent hearing the whinning.

I am a doctor in Taiwan, and after decade of health insurance policy, the situation of all healthcare stuff (doctors and nurses) are no better than hell. And the specialties in Internal medicine?Surgery?OBS/GYN?Pediatrics stop practicing increasingly, because of low pay and high risk of lawsuits. I can say, this will be the situation in US years later.

Thank you for pointing out some of the irony in eaglesfanintn’s commentary.  Calling Dr’s morons and using “crap” in your argument is laughable.

@Scott Hill I think it is you that knows nothing about the economics of a medical practice. $47 dollars/hour is generated, but this does not take into account practice expenses, which usually are around 50%. Therefore, he is actually earning $23.50/hour to put a person into a drug-induced coma, keep him alive while a surgeon operates, then successfully wakes him up. All for about half of what my hair stylist brings in.

@DeejayAustin  @eaglesfanintn There is no such thing as an Obamaphone.  It is very hard to take the author seriously after that statement.

@jkriegel8  When somebody works for a salary as opposed to a fee for each patient they see, the trend will be far less patients being seen. If the practice/physician is going to earn the same amount of money, regardless of the income they pull in, they will do less. It’s human nature. Now, since you want salary and you understand human nature, I’m sure you won’t mind having to wait 6 months for a specialist instead of the normal 2-4 months right now. 
And good luck firing your staff since there won’t be a high replacement availability. With a physician shortage already in this country (i.e. PCPs) it will be difficult to find competent physicians who want to work in this already bureaucratic field.

If you think healthcare is over-priced then stop using it.Or as a Polish citizen/resident how they like their “free” healthcare (and super high taxes) in which they are “treated” in a half-assed manner. There is no RIGHT to healthcare by a physician. There, however, is the right to manage your lifestyle (eat right, exercise, don’t smoke).
 
If you’re bitter about a physician expecting to be paid a certain amount then please lead by example. Tell your employer that you’ll go ahead and work for half of what you make now. The catch?? You don’t get to complain that you have thousands of dollars in student loans or that you spent countless, sleepless hours studying to pass your college exams, or that you sacrificed family holidays because you were on call during residency or your fellowship. No, you don’t get to complain that even on your off hours when you’re not making any money (like at your kid’s football game) that people seek your expertise and you don’t get annoyed or tell them that it’s intrusive to bother you on your personal time. 
 
Since you’re leading us by example, please don’t complain when you go further and further into debt because you can’t afford your licensure as required by the state and federal governments, you can’t attract clientele because your practice is no longer in the green and can’t afford the latest technology, and you’re essentially living a martyr lifestyle. And thanks for doing that with a hearty smile!

@jkriegel8
While your altruistic notion of physicians solely being in it for “the greater good” is sweet, you are liberalizing the point. I am not a physician – I am a Registered Nurse. Physicians and healthcare employees are working at maximum capacity already. Our physicians deserve our respect for their value and ability. They earn what they are paid. By giving away healthcare like at a firesale, we will see the erosion of ability as our standards are forced to be lowered to accomodate the ballooning need. The system will become so clogged and strained to the point that it will resemble today’s factories – people will eventually confuse volume for value. And I do agree with some that the only people profitting from the whole mess will be politicians, insurance companies (Wall Street) and lawyers. Bottom line: The government should not be FORCING the free people of the United States of America to buy something. Altruism, however noble, should NOT be forced upon us! Free people should have the ability to be charitable not the OBLIGATION to do so to help politicians pay for their votes. Doen’t it anger you that the politicians do not have to submit to the same healthcare system they are imposing in the rest of us?!

I am a Canadian doc, practising in Canada. While we certainly have our gripes, I think that things are a bit easier here as well. There is ONE insurance provider here – the government. The medical association’s negotiate the fee schedules with the government. Healthcare in Canada is considered a right, not a privilege. That being said, there is no doubt that a doctor in Canada is not going to starve to death. I also have the luxury of treating patients without wondering what insurance they have and if it will cover what ever health care they need.
 
We also have a lovely thing here called CMPA – Canadian Medical Protective Association – our malpractice insurance. Firstly, the courts in Canada do NOT tend to award huge malpractice settlements. Second, CMPA knows that the only thing a doctor has worth much value is their reputation. If we get sued, we call CMPA. They give us some advice, and get their medical experts to review the case (This is my understanding – haven’t been sued – yet) If their experts determine that there was malpractice, they settle, immediately. If their experts determine that appropriate care was given, they will not settle. Period.And the law firms that represent CMPA are some of the best there are. Other lawyers think 2 or 3 times before taking a malpractice suit against a doctor.
 
So, in short,  it is possible to make a living, a good living, practising as a doc in a climate of “government controlled” health care coverage. It all depends on how it is done.

do you realize the extent the United States finances global healthcare? You may have a great deal in Holland, but how much R&D dollars are you expending in The Netherlands that imakes the technologies and drugs you use every day available to you? The author is dead on in this article, but the whole story goes beyond his points. Simply stating that the US can adopt a system in use in another country completely ignores the role the US plays in financing global innovation in healthcare (which makes it much cheaper for all of you, allowing you to have the “great system” you have today). If the US adopted the Dutch system, R&D spend would fall off the cliff (from the Abbotts, GE, Pfizers of the world) and in 50 years the world would have the exact same medical technology available as they do today. Is this acceptable for you?

“Be efficient, caring, and empathetic rather than blaming and angry and see where you go.”
You are asking doctors to live under a fixed reimbursement scenario (accepting a relatively small fee for a give service, as shown by the $285 or so payment for services in this example), but are forcing them to live in a free market system when it comes to costs. Costs are increasing year over year, yet reimbursement rates for services is falling each year. At some point the line intersects and not only are doctors not making a profit, they are no longer covering costs. This is obviously not an acceptable solution, yet the public keeps voting for people who want to accelerate this movement of the curve. The end result will be less doctors available to treat patients, and more patients with a “I am entitled” mentality (which they don’t want to pay for at all).

Sorry, P, but it is a total myth that one can look at two vastly complex systems – one working and one not working – and just imitate a handful of attributes of the successful system and then the other will be fine.  MANY of the fundamentals – especially the history of the system and environment – can negate the impact or value of an “imported” attribute.

@emdocarizona  @GShelton 
Fantastic illuminating comments. Someone who actually understands the realities! Sir, i applaud you.

You didn’t build that organic chemistry course pass society did…mkay got it…so clearly now…. it all makes sense. Only 252k last year as defense counsel, 70hr weeks and travel keeping doctors and other producers alive….I expect to hit 2000k in the next ten years as I bulid book. We are not average. What will you do when we and our bright children start taking civil service jobs at at 85k to 120k for a year for 30hrs. a week after breaks away from the average people who currently occupy those slots? Believe me, we will, because we aren’t busting our humps for charity or working with  gun to our heads, that’s for sure.

As a physician, I have $226,000 in debt at 6.8% from the government. That’s nearly $2,000 a month over two decades for a total of $414K. Malpractice insurance in the state of NY runs about $97,000 a year, because tort reform is utterly inadequate. For those of you doing the math, that’s almost $150K a year that goes down the tubes. For someone who goes through training until the age of 35, the math doesn’t add up.
Most of you don’t care about those numbers. You should. Because the reality is that any physician that has a choice will no longer serve the lowest reimbursing patient classes (i.e.: medicare and medicaid). Hospitals in inner cities that serve these populations will also close, and new hospitals will be built in more affluent areas. Just because you have Obamacare/medicare/medicaid does not mean that you will have access to healthcare, because there will be a shortage of providers who can afford to take care of you. Possibly younger providers without medical school debt and less training will be able to. For myself, I’ll be manning an emergency department near you, where I will likely see all of the Obamacare/medicare/medicaid patients, because they’ll have nowhere else to go.
Until the hospital closes my emergency department and moves it somewhere else.

@Dan mason I think you need to get your facts right. Rationing isn’t the big thing in Europe that you say it is. Where there is universal coverage (or near)… Doctors work and health outcomes are good to… Look at Sweden, Belgium etc

@Doc in Training Oh dear I fear the point”caring” profession is not for you.

@Jen J Well you lived in a different England to me. The health outcomes stack up well (especially compared to the states) waiting times are not problematic, proportionate cost is low (again compared to the states) and life expectancy is excellent. England is not the basket case here.

Wow… so much comment and so much passion. US does not have to fix anything if it does not want to… but look at the facts OECD, WORLD BANK or wherever you want to get the stats… You pay more for your healthcare than anywhere else in the world! Unfortunately your outcomes are arguably average at best (when compared to similar economies). There is a problem, how you solve it, if you solve it , is up to you but think on this if you create an inequitous system it has a far greater impact on your overall economy than you think…. healthy people work harder and are happier… happier people work harder and spend more…
Good luck with the posturing Dr Smith.

@Doc in Training  @kidneykim
 I am very sorry for what your dentist told you.   As a practicing dentist with $205k of educational debt NOT subsidized by the goverment, a patient with a problem is a patient with a problem.  The amount of time spent is dependent on the severity and/or complexity of the problem.  I NEVER look at how a patient is paying me.  I do, however, limit the number of PPO patients seen in my practice. With an overhead (77% split between 2 providers) we cannot survive as a business if those numbers are any higher than what we currently treat.

@Mrscrod  @Erdrfl Reread my post.  I said no such thing!  What I am telling you is that the ONLY way that healthcare costs are going to be controlled is rationing care, and that includes “death panels” or even simply denying payment for certain procedures in certain high risk populations (another form of “death panels” that insurance companies currently use).  I do not agree with this, but it is coming.  Mark my words.  This is what the “majority” of Americans voted for.  Don’t complain to me in the future when I have to deny care because the government says that you are not worth the price of saving you.

@Dan Rittmann  I believed he was referring to programs like the one described here: https://www.safelinkwireless.com/Enrollment/Safelink/en/Public/NewHome.html

@mandie21184 I am sorry but your comment really doesnt make much sense.  If you think healthcare is over priced then stop using it?? We hmmm then I would go to prison if one of my children die or I could die and then where does that leave my children?  A change in lifestyle isnt going to stop all the things that kill you. Health care is not an option sometimes and some reform should be done yes but more so in the underlying costs. Doctors should be paid well we trust them with our lives and our loved ones lives. I would much rather pay a little more to know I have a qualified doctor over one that has the lowest level of training.

@DavidBr    Yes, sir, it is.  Many pundits and commentators take the “tribal” method of repeatedly dismissing  points mentioned or discussed on Fox News so that a biased group of followers will buy that *everything* mentioned on Fox News is thus absolutely wrong – simply because it is on Fox News.  That  linkage and method can now be conjured up with the simple label of “Fox News talking point”.  To the broader point, such spokespeople would have you believe that *large* groups of people (like people who watch Fox News or all Republicans, or (even larger) all people who vote for Republicans can be so homogeneous as to be *always* wrong, in all things and all absent any value at all.  That, sir, is as objectively implausible as it has always been when wrongly applied to African Americans, women and other large, diverse groups.

@Unsocial healthcare Hmmm I think we can all quote examples of bad practice, its not going to take the argument forward. Look at the facts; what do the OECD figures tell you. The US spends more than ANY other country but still a sizeable of your population gets pretty cronic health outcomes. Not bothered… Don’t do anything about it.

@IDespiseTheLeft. Of course you do… The rest of the world doesn’t pay a penny we get it all for free….

@DrGMan  @jkriegel8
 DrGMan, I am looking for a good physician…I’ll take you any day!

@BethLohr  @jkriegel8
 Beth, I am a blue collar worker and pay for good coverage right now, but in the past couldnt afford coverage and i STILL agree with you. Innovation will also go outthe window..how many will put the time in for no extra pay to come up with new treatments and cures? This will kill the most innovative health care in the world!

@Mrscrod @Erdrfl I am in the adult intensive care as an RN. I think what “Erddrfl”. Is getting at, is that all too frequently we do things to our elderly that they nor the family would want. The end do life discussions NEED to happen BEFORE these situations arise. I can’t tell you the number of times we have intubated (breathing tube to lungs) an elderly patient only to have the family come in and say with tearful eyes, “They would have never wanted this” or “they are going to be so mad we did this to them if they make it through this”. Until you see this, a frail elderly person tied to a bed (so they don’t pull their tubes) with tubes hanging from their mouths, you can’t understand the sickness I feel doing this to someone in their twilight years. We nurses often say that we treat our dogs better than this. It breaks my heart. And to top it off, then the family is all too frequently left with the decision to “pull the plug” when everything we can do has been exhausted. How many want to do that to their loved ones? Whether you are the one to make the decision to stop the life support, or the patient. So when you say the family will decide, how many are really ready? Know your loved ones wishes. Check with your state laws about power of attorney for healthcare papers. This will save heart ache, guilty feelings, and yes, lots of money.

@Dan Rittmann Just an FYI; there IS a free cell phone with 60minutes free time per month. Check your phone bill, you will see a “tax” for it, or Google it. This is why they call them “Obamaphones”.

@Calamity Sane I too, am a nurse of 20 years. I like the trial idea, too bad we cant get enough common sense in D.C.! At any rate, I have read parts of the ACA bill; and found how they plan to fix the rural problem. Medical students now can only get loans from the Federal Gov’t. They sign a contract that says when you graduate, if the loan cannot be paid off, then they will send them to an “area of greatest need”. Now if THAT’S not INDENTURED SERVITUDE, I don’t know what is!

@Dr Anderson My father was hunting in Alberta, Canada. He thought he was having a heart attack. The first hospital he went to refused to see him (an Amercan citizen). They told him where else he could go that might treat him. When he got there, they would, but not until he paid cash first. He had to get money wired to the hospital from the States. Thankfully, it wasn’t a heart attack. So his problem was, he didnt have an insurance card. On another note, I worked in Detroit. I can’t tell you the number of Canadians that came over for heart surgery because they didn’t want to wait. Why is it wrong to want to be paid for your services? I went into nusing because like you, I care. So, I keep going back, even though I just got a $2/hour pay cut as an intensive care RN. Because I love what I do. But it is the author’s choice whether or not to sell his services. He can set his price, and people can take it or leave it. At least for a little while longer.

@Penumbra_Paradox Google “free cell phones low income”. Don’t believe just one source for your research. They DO give out free phones. And, free air time.

@mandie21184 Complaining about all the hard work you put into becoming a doctor…not my issue you chose the profession. Perhaps if money is what you were really seeking you should have chosen a different profession…you know something like hedge fund analyst.

@crisdp720  @Unsocial
 The disturbing health outcomes related to chronic disease in the US are more a result of Americans’ irresponsible lifestyles than the healthcare that we demand to save us from the consequences of those lifestyle choices.

The plan Mitt Romney put in place in MA is VERY different from what we have gotten in Obamacare, aside from the mandatory coverage requirement.  The MA plan certainly did not add scores of new taxes on everything from home sales to bulk diesel purchases, or many of the other control measures many here are talking about.  if you think that is “foolishness”, perhaps you should *read* the ACA.

@Momtran  @Dan The legislation was signed by Reagan and again for cell phones by George W. Bush.

@Momtran  @Dan  Snopes says partially true, partially false with this one. ^[10]
 
Also, the Universal Service Fee covers four programs, not just low cost phones. ^[11].
 
Finally, this program started under Ronald Reagan and TracFone started under W.

@DeejayAustin Signed by Reagan and again for cell phones by George W. Bush.

@Mrscrod  Maybe you missed it Mrscrod, but there already are death panels. Insurance company executives whose income increases with every claim they deny decide what they’ll pay for and what they won’t. What? You need a liver transplant but your insurance company decided it’s an “experimental” procedure? You’d better just get your affairs in order, because the death panel just handed you your sentence.

To those saying doctors are poor, there is something rotten in Denmark… and its a lot of your mathSo I ran the raw figures through an extensive excel spreadsheet designed to calculate net worth after figuring in median salaries (salary.com), average student loan debt with payments made on the standard 10 year plan (average of various web sources), taxes paid incorporating student loan interest deduction (tax estimator:  H&R block), malpractice insurance.  I did not incorporate inflation or changes to law/reimbursement rates as those can go up or down with time.  I also used the average number of years of residency as well as data on earnings during residency with the assumption that no payments are made on student loans during residency with deferred interest accruing and capitalizing on the loan until the completion of residency.  I also assuming that there was a zero dollar differential opportunity cost as all my projections start with an identical 22 year old graduate with a 4 year degree in a science field with no work experience and direct entry into his or her professional school in the healthcare disciplines and a work-life duration until the social security determined age of retirement of 68.  Comparing dentistry, medicine, and pharmacy, the worst off financially is the clinical pharmacist with an average net lifetime earnings of $2.67 million.  A primary care physician, by comparison, despite their additional years of schooling and higher loan payments after deferral earns approximately average net lifetime earnings of $4.73 million.  Lifetime earnings for dentists was difficult to calculate given the annual income range is widely variable by over $100K in different parts of the country.  With an averaging function, I figured dentists earnings per lifetime was $3.2 million.I compared my numbers to a study done at Georgetown ( ^[12]).  They did not incorporate loan payments,malpractice, or income tax and after subtracting those from my calculations, I arrived at numbers which were +/- 200K of theirs.  Considering it took me 30 minutes to put together my raw calculations, I consider that to be valid and confirmed.So doctors, don’t try and sell me on your hokey math.  You are not “poor”.  You may be in school longer and have higher student loan debt, but your ability to pay that debt is unparalleled because your average salaries are far in excess of those of the other health professions.  Everything you say about the difficulty in managing student loan debt may be true, but that makes it even more challenging for persons of other health professions who accrue similar levels of debt as physicians (on the order of 200-300K).  So if you say you are struggling, others are living in a cardboard box.The hey day of all of our professions earning substantially higher incomes is gone.  But this is the life we *CHOSE* to lead.  No one held a gun to our heads and made us do what we do.  We chose this life knowing that we would never be as wealthy as the physicians, pharmacists or dentists of yesterday.  We just need to accept that reality and identify a path forward.  That path forward means we need a system of reimbursement which rewards the professionals for creating the best health outcomes.  This does one very important thing:  redistributes income from poorly performing members of our professions (and we all know who they are!) and gives it to the high performers.  Its no different than being in finance, construction, or concert piano.  If you are the best at what you do, you should be paid accordingly.

You pay a lot because you want a lot and generally you get a lot!
You have tthe biggest expenses because you have the best medicine (the best healthcare system does not exist!).
The author is completely right!!! Do belive him!!!
If you don’t, make a visit to Romania to see what happens in our health  system, still too comunist, even after 22 years of post-comunism! After that, be sure you will belive!

I do find it funny that doctors and bankers (insert wealthy overpaid job here) complain about all this but still expect police, army, firefighters (insert underpaid service profession here) to support and provide a service to them through taxes but it doesn’t work both ways. I’m always so happy to be British and living in England especially after living for 2 years in the states. I especially enjoyed paying over $100 for oral suspension fluid for my young one when she was ill, the same solution I can buy in generic form off the shelf in the UK for about $8. I think the problem is where the government is paying a private medical system rather than it being government health care with a separate private healthcare. Our doctors still live a very good lifestyle but probably alot more modest than the gentleman who wrote this article. Maybe we should privatise the police etc and they can charge him similar fees to protect him from these ‘mobs’ waiving insurance cards at him. Firefighters can check his credit before putting out the fire in his house (which was how I felt using the US health care). The military may then get a decent wage before offering their lives up to defend him both at home and on foreign soil. I find this guy a joke.

@Momtran  Yeah, but they should call them Reaganphones (for landlines) or Bushphones (for cell service). Might as well pin Pearl Harbor on Obama, too.

@Healthcarerealist Using your figures….
A new college grad making $50k a year (with just undergrad loans) would bring in $2.2M over their 44 year work life…and a ‘high demand’ degree such as Petroleum Engineering ($98k starting) would bring in $4.3M.     No, Doctors aren’t in general ‘poor’, but they certainly don’t make as much as a lot of people believe (especially factoring in student loans and the stresses of their jobs).

@Healthcarerealist I should add:  Rather than try and factor in taxes, etc…I just multiplied the starting salary of each (Petroleum engineers earn about $150k mid career) by your ‘work lifespan’ for them.

@anonymous123456789 Of course I agree that physicians don’t make as much as many people would believe.  And there is no denying that physicians are stressed on the job.  I also don’t think Obamacare is good for the country.  I think private markets can function perfectly well if certain regulations which promote monopolies and distort inefficiencies were eliminated.  But I am VERY annoyed with physicians complaining about their ‘destitute’ lifestyle.  While we all know of the anecdotes of some physicians movin’ back home with the folks, its not the norm.  In a financial sense, most doctors do perfectly fine.  When I hear them talk about the magnitude of their student loans, I know that they will pay them off in HALF the time it will take me.  And they complain *they* are struggling?  Right… Tell that to the teacher who has 50K in debt with a 35K salary.

The joke is that people come from the UK to the US to get procedures done to save their lives rather than see if they can outlive the waiting list there.

@DrGMan And your point? I could afford up to $200k with the difference between mine and the average anesthesiologists salary. Even with tail coverage I wouldn’t hit that, even in Chicago.
Plus, Med Malpractice is a write off as a business expense. If your accountant isn’t recovering some of that cost find a new one.  Plus, are you doing a risk assessment and adjustment to determine your coverage amount? Are you looking into the possibility of joining a physician’s practice to gain benefits from that?

@WillGanz No, the joke is that people believe fairy tales like that.

As usual, the author cherry picks numbers which make his or her argument look good.  If we posit that we are in agreement with the numbers in the above post, then one of two things must be true:  there are no anesthesiologists working (because no one could afford to be one) in the United States or the financial impact of low reimbursement is surreptitiously overcome through other ancillary billing. In no world in which we live does an anesthesiologist actually earn $47.50 per hour because such poor reimbursement does not cover costs.  The physician is also paid from the thousands of dollars under ‘professional fee’ which is billable and the hospital and/or physician can charge higher costs to the patient as a “co-pay” of sorts.  A hospital may be required to treat a patient in emergency rooms for life-threatening cases, but they are not required to do so free of charge.  In the same vein, hospitals are not forbidden from charging patients for other ancillary costs to cover the cost of the admission. 
 
To completely debunk the ENTIRETY of the original article, as well as this post, the median salary of an anesthesiologist is reported to be $290,000 (source:  Salary.com, Money.cnn, multiple others).  If a physician was truly reimbursed at $47.50 per hour, yet earned 290K, that would mean the physician worked 6105 hours in a calendar year (6000 hours is a 120 hour work week, every week!).  So either physicians are paid through other mechanisms, or the conclusions of the article are based on misleading, cherry picked data designed to have a WOW-factor but doesn’t pass the test of common sense.  That’s because there is a BIG difference between reimbursement rate and hourly wage.
 
Here’s the numbers for a pharmacist: 1.  4 years of college
2.  4 years of graduate school @ 50k per year, also out-of-pocket
3.  1-2 years of optional residency (but increasingly popular) with 80 hour weeks and a pay rate of $9/hr, many of whom then go on for further fellowships, specialty certification (e.g. BCPS)
4.  250000 of debt after pharmacy school
 
Independent Pharmacy Expenses:
1.  8K in monthly rent
2.  200K in perpetual inventory
3.  100-500K franchise fee
4.  100K in computers, data storage, EHR, IT support, equipment, auditing, etc. 
5.  Salaries of several employees
 
Reimbursement:
The Deficit Reduction Act of 2005 (DRA) reduced the maximum amount of federal money that states would receive for generic drugs dispensed under the Medicaid program by lowering reimbursement amount to 250% of the lowest average manufacturer price (AMP) value of a generic.  Studies by the General Accounting Office show that this reimbursement figure is between 17-36% lower than the true acquisition price of medications.  This means that without even considering overhead, salaries, or any other costs, the reimbursement from government for Medicaid prescriptions is less than the cost of the medication representing a guaranteed loss for the pharmacy for every one of those Medicaid prescriptions. Worse still is the fact that while doctors are free to choose which patients to accept in their practices and can thus avoid accepting new patients which erode their profitability, in most if not all states, pharmacies are not permitted to discriminate based on insurance reimbursement – we must serve our patients regardless of how much money we lose on their prescriptions.
 
Even worse still is that in some states, such as the state of Maryland in which I practice pharmacy, the $1 co-pay required to be collected from the Medicaid patients for most of  their medications is legally waived if the patient states he or she lacks the funds.  The pharmacist is not permitted by law to deny the medication to the patient and must dispense. 
 
Medicare is only somewhat better.  While pharmacies lose money on nearly every Medicaid prescription, they only lose money on some medicare prescriptions.  Without mentioning specifics, my pharmacy has seen prescription growth or nearly 10% over the past year but the margins and net profit have fallen by 3% due to lower reimbursement rates and an influx of more patients from Medicaid.  And unlike doctors, I am not permitted to turn them away – by law. 
And the cherry on top of the sundae which is our woe, some physicians have found it lucrative to dispense select medications from their office which skirts many laws and openly violates others – this excludes the normal practice of dispensing samples or starter doses which by law in many states is limited to 72 hours of therapy.  Physicians who dispense are legally required to follow all the laws and regulations which govern the practice of pharmacy including procuring a dispensing permit and I know of exactly zero physicians who follow those regulations.  Appeals to the board of medicine for pharmacy oversight over physician dispensing only are met with ridicule and derision – as if a doctor of pharmacy would know anything about the safe dispensing of medication!  If the laws which govern dispensing of medication were indeed erected in the interest of public safety, what then could be the origin of physician opposition towards maintaining public safety?  So not only are physicians  breaking laws, threatening patient safety, they are doing so to make a quick buck while pushing off costly, low-margin prescriptions to pharmacies while keeping the high-margin, low-cost prescriptions for themselves.  
 
Recap:
So while the doctor has means for making up the costs of poor government reimbursement by charging other expenses to the patient – I am forbidden from doing the same meaning I am LEGALLY required to lose money while the doctor does just fine.  And while I have comparable loans, the cost of running the business is comparable, my salary is 60% that of a family physician, and a mere 38% of the anesthesiologist making it several orders of magnitude more difficult to manage the finances.
 
Obviously, my initial argument applies to myself as well – the sheer existence of pharmacies, even in locations with high-density indigent, Medicaid paying patients, indicates that we are not losing money on everything – or else we would be out of business.  We are fortunate that we have over 50% of Americans with private health insurance plans which offer higher reimbursement rates which make up for the deficit incurred by Medicare and Medicaid patients.  We are profitable thanks to other revenue streams as a result of dispensing medications to patients with non-government assistance insurance.

Medicine has become more focused on finances as a reference than whatever the original mission was.
“You should not select me as i have no use for you or your existence as you have not the funds to interest me.”
At least that statement would be honest. I don’t blame anyone that takes that side so long as they are up front about it. ‘ Your money or your life’ used to be a joke. Now its real.   Just think when there are 9 billion potential patients in the world if 7 billion has us up against the wall now. Something to look forward to.

@kidneykim  @mandie21184
 Well, if you you have ever visited a second (or third) rate doc and received poor care, then you would change your tune.  There may be some physicians that go to med school thinking they are going to be a billionaire, but many physicians attend med school for the correct reasons.  And they spend a lot of time and money to help you and your loved ones.  You should not be so callous about people who try to do the right thing.  And no, I am not a doctor.

@Healthcarerealist the arguement from you and from the article are both filled with some facts that are not debatable. Are doctors poor? No. Are pharmacists poor? No. Are ALL healthcare providers going to suffer significant pay cuts in the very near future? Absolutely.
The arguements by you and the author are all relative to prior experiences. (And I am absolutely certain that all of the doctors in your state are NOT dispensing highly reimbursement medications and leaving you the low- margin medications to dispense. Let’s “dispense” with the hyperbole, shall we?). Since when is competition a bad thing? And if there are doctors not following the law, report it to the authorities and quit whining. (Don’t worry! The government is here to save everyone!)
The issue at hand is that there is only so many dollars to go around and there will be no more spending like drunken sailors (no offense to the Navy). All will take cuts. Some practitioners will stay and some will go (me being one, if I can). Am I poor? NO. Am I underpaid for what I do (emergency medicine)? Depends who you ask. I am overpaid if you never need my services and your life does not depend on my healthcare team (including our ED pharmacist, who we LOVE having as part of our team). If you are dying and we save your life or your loved one’s life, maybe we’re not so underpaid.
We can all cry poor and we can all have legitimate complaints about our lot in life. We all picked it. We are all paid pretty well for what we do. (I have yet to meet someone who thinks that they are overpaid for what they do, though I have seen a lot of people complain that others are overpaid for their job).

@Erdrfl  @Healthcarerealist Erdfl has hit on the point that the correct relativism here is not whether doctors are overpaid in comparison to bookkeepers but to compare what was legitimately expected as a result from a ‘plan’ and what is *now* the result.  How many people would happily agree to a 50% cut in compensation from that objective that justified their entering their hard-won, life-long career path.  And, yes, we are ALL facing that in some form and to various degrees.
 
I really wish we could stop prosecuting the 1% v 99% battle and recognize the THREE factions here that I call makers, takers and fakers.  Makers are those who, with talent, hard work and whatever opportunities they encounter, *produce value* for themselves and society.  Takers are those who, for *whatever* reason are net receivers of value. (Note:  *Some* have no choice and *cannot* produce value; others *choose* not to produce value, and we don’t need to delineate who fits into which group.  To say that NO ONE chooses not to create value is absurd.)  The real point I want to make is that the fakers are the real culprit.  THOSE are the ones who build and work “the system” in which the makers and takers are polarized while they (the fakers) are getting rich off the process and the antagonism.  This is EXACTLY like the bookie who gets rich no matter who wins and looses the endless stream of contests of one side against the other. Does ANYONE think the politicians, pundits, activists and operatives that are fulminating the %1 v 99% battle (also know as the “middle class”, the “oppressed”,  ”disfranchised”, and “union workers”)  the most are POOR ?  They work very hard to make it seem that they are just big-hearted, but they have figured out the means and context in which to ENRICH themselves from it. They aren’t delivering value so that people and businesses *want* to give them money; they only create a contrivance and a control mechanism by which people and businesses are FORCED to give them money.

@Healthcarerealist
 To clarify a few of your misconceptions:
1. Doctors cannot change “co-pays” (or charge additional “professional fees“ to patients), as a patient’s co-pay is determined by his/her  insurance plan.  Doctors can be sanctioned under the Medicare False Claims act for filing false or inflated charges.  Also this is considered a “breach of contract” in the eyes of the insurance company, who will then as a result no longer contract with that doctor.
2. A hospital is required to treat patients in the ER free of charge, if the case may be (all patients must be treated in the ER, regardless of the patient’s ability to pay, failure to do so would violate federal laws such as EMTALA).
3. Medical school are more competitive to get in to, in general as compared to pharmacy schools.  Also the optional pharmacy residency is on average 3 years less than the average medical residency. Training is also more rigorous in general.
4. Pharmacists generally would not need to worry about paying the Independent Pharmacy Expenses mentioned in your post, unless they own the pharmacy.  Similarly, doctors who own a practice would have to have sufficient reimbursement from insurance companies in order to pay their office overhead, whereas staff physicians would not (and so would have a lower salary or hourly wage, as they didn‘t have expenses).
5. It is true that doctors can decide not to accept Medicare and Medicaid patients.  However in many areas this would eliminate 60-90% of all patients in the area, and so the doctor would have no patients (so many doctors don’t have the luxury to deny seeing patients with Medicare).
6. I cannot personally think of any doctors who push “costly, low-margin prescriptions to pharmacies while keeping the high-margin, low-cost prescriptions for themselves.”  What evidence do you have to support this accusation?  How many physicians are consistently breaking dispensing laws, and are they the rule or the exception?  Please give data and statistics to support your statements.
7. I will again reiterate that your recap is incorrect in that private doctors have no means of making up the costs of poor government reimbursement by charging other expenses to patients.  That is why many private doctors are closing up shop because Medicare/Medicaid reimbursement rates have been decreased to the point where it’s not enough to meet expenses.  Also, you can only compare a private, independent pharmacy to a private doctor’s office, as chain pharmacies (e.g. Walgreens, CVS, Walmart, etc.) enjoy economies of scale.
8. There is not much point in comparing salaries or hourly rates, as that would be like having a pissing contest.  I could complain about plumbers who charge $95/h.  Or that my father, who is remodeling his home in San Francisco, is being charged $150/h by his interior designer.

@clicky  @Healthcarerealist  Very well written and explained, except for 1 thing. The 60-90%. Where are you numbers and stats on this? That depends on the area. Small rural areas may have a larger per capita as do some inner cities. However, some of the retirement areas such as Lady Lakes or Clearwater, FL. Have some very well to do individuals who actually opt to pay their physicians cash for a private physician and contract them for a fee of anywhere from $5,000- up for basic care which includes house calls.The docs take on only 300-500 patients.  Nice deal. Some doctors are opting to do just that, accept cash only. I do not blame them.Not a bad deal for all concerned.
 This means no HCFA”S to fill out no hoops to jump through, no mailings, no waiting for reimbursement at a lower amount than billed.
There are going to be many individuals that will pay the fine imposed by Obama care and pay cash for their Dr.’s visit pure and simple.
Quite frankly I do not blame them.

@Calamity Sane  @Healthcarerealist
 Calamity Sane,
the 60-90% is not based on any hard data, but solely my opinion on the percentage of Medicare/Medicaid patients that make up all the patients with insurance, in rural/low-income areas. 
 
Yes, you are right that those who are able to afford “concierge” medicine will choose to do so, and the doctors in that area will be happy to provide them these services at a hefty fee.  In general, I am not concerned with the wealthy who can afford this service (as they will be able to thrive and survive regardless of the President and the politics), but more concerned about the average person who is living day to day on Medicare, Medicaid, or no insurance.

@clicky
There are some legislative falsehoods in your reply… and some misconceptions about my reply.  My point was not to compare pharmacy to medicine… but to demonstrate that using valid statistics assembled in a specified sequence can “prove” any point desired.  Its basic math – no physician works an annually billable 6150 hour schedule thus the outrage over 47.50/hr is misplaced.  There is a difference between billable service reimbursement and SALARY.  The average salary is considerably higher than the federal reimbursement rate proving doctors must be receiving remuneration via alternate revenue streams.  It is for that reason why I specifically stated that the existence of pharmacies in indigent neighborhoods demonstrates we can be profitable despite losing money on many if not most patients.  Anyone can cherry pick statistics to ‘prove a point’.  
1)  I put “co-pay” in quotes because there are charges which can be submitted to insurance companies which are non-reimburseable which then become a charge to the patient – a defacto “co-pay”.  If the patient doesn’t pay, the medical practice can boot the patient from the practice – this is different from pharmacy where we are required to take a financial loss and keep taking it.  I cannot kick patients out of my pharmacy and tell them to find another pharmacist.  Nothing in US federal or state law requires a physician to continue seeing patients regardless of unwillingness or inability to pay their bills.
2)  You are incorrect about EMTALA which applies to hospitals – not doctors.  It states that a patient must be given appropriate care regardless of ability to pay until the patient is stabilized or walks away AMA on their own cognizance.  But it NEVER states that services must be provided at no cost.  It also has provisions where hospitals may sue patients to recover payment for services provided.
3)  We cannot compare difficulty of our professions.  W made a conscious choice when we entered our professions.  What about the man who picks up trash or the man who works in sewers?  Labor laws state exempt employees aren’t entitled to a lunch break, but there is a difference between being entitled and being forbidden.  The law states that pharmacists must be on duty to serve patients during posted pharmacy hours.  If the pharmacy posts a closure at lunchtime (as many large retail stores do such as Walmart, Costco, Sam’s Club, Target, etc), the pharmacist may take that break.  If not, as in the case of CVS, Walgreens, Rite Aid, and most if not all independents, I must be available to serve patients – sometimes for 17 continuous hours.  But again, these aren’t things that are heaped on me at the last minute – I CHOSE to enter pharmacy.  No forced me and no one is keeping me here.  We all have different challenges in our professions and they are not comparable.  Most if not all doctors do work hard to get where they are and to stay where they are.  No one says a physician’s job isn’t stressful – but it is a stress and workload the physician chose to accept as part of their profession.
4)  To the same degree, staff physicians need not care about the overhead of staff, rent, etc.  40-50% of prescriptions are processed by independent pharmacies.  Contrary to common perception, it is not a small segment of the market.
5)  There remains a fundamental difference in what is legislated because regulations drive everything (isnt that the point of the OP/article?).  Physicians can make a choice about accepting/rejecting low-reimbursement patients.  Hospitals cannot choose patients and cannot deny treatment, but can still charge a patient for services.  Pharmacies cannot choose who they see, must give medication, and co-pays must be waived if requested.  We are legislated into losing money.  That is a fundamental legislative difference – physicians have a choice and pharmacies do not.
6)  Many physicians dispense.  In workman’s comp cases (one of the first big studies on physician dispensing – ^[13]), some states had over 30, 40 and even 50% of prescriptions in workman’s comp cases being dispensed by physicians.  Average markup ranges from 60-300% greater than the pharmacy costs which have reimbursement rates pegged to AWP whereas physicians can create their own “AWP” because physicians purchase from repackagers for physician office sales which then creates a new, higher AWP with larger margins.  Its also just common sense – for a physician who dispenses, s/he will not keep in stock expensive medications used with more rarity because the more expensive the medication (brand), the lower the margins.  It is also known that the profitability changes what medications are prescribed (questionable ethic!).  In states where physician dispensing is rare, H2RAs and PPIs are rarely prescribed in WC cases (<2%).  In states where physician dispensing is common, H2RAs and PPIs make 8-11% of prescriptions in WC cases.  In those states, pharmacies sell OTC H2RAs for about 70 cents per tablet but physicians are reimbursed between 3-7 dollars for the same tablet.  Don’t try and convince me that there is more GERD in those states! 7)  Of course chains enjoy economies of scale – that is why my example covered an independent pharmacy only.  Independents have overhead and costs just like physician offices.  Physicians routinely bill for services which were not provided or overbill for services not needed.  CMS estimates $50 billion dollars in fraudulent Medicare billing alone. More billing for the same work – pretty sweet deal!  If overbilling was eliminated nationwide, it could cover healthcare for every citizen with some estimates ranging from 300-500 billion.  Do all physicians behave unethically?  Of course not!  But it is not a rarity. 8)  Agreed. My point wasn’t to compare salaries, but you have to understand how the 97% feel when doctors say they are “poor”.  When you think of these professional athletes like hockey players making millions of dollars each year and then shutting down an entire season over a few thousand dollars this way or that, how does that make you feel about the players’ and owners’ greed?  The country feels the same about physicians complaining about their pay. 
In the American healthcare system, there is no direct relationship between healthcare cost/provider salaries and health outcomes.  In the current world of healthcare, we are fundamentally financially advantaged by promoting a state of unhealth among our patients.  Doesn’t that bother you?  It certainly bothers me.  Restructuring healthcare to a a system where the primary care physician is a health case manager developing individualized strategies for patient care executed by other members of the healthcare team, especially in regard to chronic disease management, with nominal fees paid for services rendered but substantial financial rewards for preventing illness or disease progression would have a strong positive impact on trimming healthcare costs by preventing costly interventions, redevelop the patient-provider relationship so that we are no longer the healthcare equivalents of McDonalds, and create an overall healthier nation.

I’ve always looked at doctors the same way I look at police, paramedics, firemen, etc. Whom by the way also save lives and make very little while risking the their lives. In other words, I thought they were good people who understood that what they do is really THAT IMPORTANT. So important, that like the others mentioned, the money would never be enough to cover the service and need, and therefore, can not be part of the deal. That doesn’t mean I deny them an income, but it boggles the mind how much they think they should earn, and how much medical school cost plays a part in their selfishness.
 
I don’t deny anyone, anything, but let’s look at the whole picture. The market, isn’t based on what you think you should earn. It’s based on what consumers are welling to pay,
 
If doctors want to be treated as say manufactures, then, doctors should fully adopt the free market. Not make one up that is all about them. In a free market, a doctor, can only charge what people can afford to pay or else there won’t be any customers (yes, Dr. Smith obviously view people as customers). So, lets get rid of insurance companies, and the government. Let’s all pay out of our own pockets!!!
 
If we do, how much do you think Dr.Smith will make? Not enough to go golfing once a month. He would be making about as much as cops do. Yup. And as for his we won’t become doctors. Well….what will you become? You’ll still have to earn a living. And what about the doctors who are driven by the passion to heal? Are you telling me they will give that up? And what will they do for an income?
 
Dr. Smith, you are an example of what is wrong with healthcare. We always had doctors, long before this absurd notion that you should decide how much you deserve, we had doctors. Why do you think that is?  
 
Frankly, I wouldn’t want a doctor like you anywhere near me.

@Healthcarerealist  
 
Healthcarerealist, you still have a few misconceptions.
To summarize my points:
In your intro, you said: “The average salary is considerably higher than the federal reimbursement rate proving doctors must be receiving remuneration via alternate revenue streams.”  This is not proof, just one possible explanation, which may not be correct.  The usual explanations for your observation are: doctors have been forced to see more patients and/or work more hours, in response to declining reimbursement rates and rising practice expenses.  Physicians decrease time spent with each patient so as to “squeeze in” more patients (4-5 patients/hr instead of 2-3 patients/hr), and/or work more than 40 hours/week (obviously not 6105 annual hours or 120 hours/week, but not uncommonly 50-80 hours/week or 2500-4000 annual hours).  This is usually what happens Healthcarerealist, rather than doctors receiving remuneration via alternate revenue streams (be it legally or illegally), as you suggest. 
1. If a medical claim is submitted to an insurance company and the claim is denied, it is illegal for the doctor to bill the insured patient directly for the denied claim.  A patient’s co-pay for medical services is pre-determined by that person’s insurance. A doctor cannot charge a higher co-pay to that patient for those services covered under that patient’s insurance, and to do so would be an illegal “breach of contract” between the doctor and that patient’s insurance company.
2a. A physician can kick out a patient from his/her medical practice, at the loss of that patient from the doctor‘s practice (but thereby losing that patient and forfeiting any income generated from any future office visits).
b. A pharmacy cannot kick out a patient from the pharmacy (unless they violate pharmacy policies).
c. A hospital cannot kick out a patient in need of emergency medical services (unless they leave AMA, then they‘ve left AMA). I am correct about EMTALA, which applies to hospitals.  Doctors who provide emergency medical services at the hospital are bound by EMTALA by extension.  “In truth, then, the requirements of EMTALA are imposed on the people who work within and on behalf of the hospital, but the hospital is the entity which must bear the loss if it is found that they have violated the statute.” ^[14] (see #2, paragraph 2).
A hospital cannot deny emergency medical services to a patient who comes to the ER even if that patient cannot afford to pay for those services (to do so would be an EMTALA violation).  If a patient has no insurance and no money to pay for the emergency medical care, then that patient must receive it for free. “A hospital may not permit a denial of payment or uncertainty about payment to interfere with its obligations under EMTALA.”  (see #13, paragraph 4).
All too common example: an unconscious homeless man, detoxing from his alcohol binge, is brought by ambulance to the ER, and he is intubated and admitted to the ICU. This homeless man recovers and is discharged a couple days later.  He doesn’t pay anything, as he has no medical insurance and no money to pay the hospital (and has no assets to sue for).  That patient returns a week later for the same reason, and doesn’t pay a dime again. 
I’ve not heard or seen of a case where a hospital has “sue[d] a patient to recover payment for services provided.”   This seems like an extremely rare occurrence to me.
3. Yes, we made conscious decisions to enter our respective professions, with their respective challenges, and to keep working our jobs.  I agree there’s no point in comparing professions.
4. OK, I see.
5.  Already answered in 2.  But to reiterate: physician have a choice to kick out low-reimbursing patients from their practices (but thereby losing that patient and forfeiting any income generated from any future office visits), but hospitals and pharmacies cannot.  Hospitals can charge patients for their services, but patients can refuse to pay if they have no insurance and no money.  So hospitals are also legislated into losing money on certain patients.
6. I was not talking specifically about Worker’s Comp cases (where I completely agree with you that there is a very high markup for dispensed meds), but I was talking about medical practices in general.  You claimed that: “So not only are physicians breaking laws, threatening patient safety, they are doing so to make a quick buck while pushing off costly, low-margin prescriptions to pharmacies while keeping the high-margin, low-cost prescriptions for themselves.”  Besides the specific Worker’s Comp situation (which I agree with you on), what evidence or statistics do you have to back up your bold statement?  I’m still waiting for them.
I and some of my colleagues routinely prescribe off of the Walmart $4 formulary to patients who lack funds or have no insurance or request the cheapest meds for their medical conditions.
7.  You state “physicians routinely bill for services which were not provided or overbill for services not needed.”  If you are so hard at work in your pharmacy, how would you know the billing practices in the average doctor’s office, in order to make such a bold accusation?  You state that “CMS estimates $50 billion dollars in fraudulent Medicare billing alone” but do you have data on estimates on underbilling of claims presented to Medicare?  It is impossible to measure this, but in my personal experience, the majority of my physician colleagues traditionally underbill, so as to avoid a Medicare audit (and the time and money resulting from addressing an audit and denied Medicare claim).  I suspect that it is the few unscrupulous individuals and organizations that intentionally and repeatedly submit fraudulent Medicare claims, resulting in the vast majority of false payouts (these lucrative payouts incentivizing them to continue billing fraudulently), whereas as the majority of physicians bill accurately or possibly even underbill. Medicare fraud and abuses hopefully will improve as EMRs will code and bill more accurately.  Unfortunately those who engage in Medicare fraud will continue to bill fraudulently on EMR as well. 
8. Yes, doctors shouldn’t complain about being poor, nor should anyone in America for that reason.  Americans are in the top 1% in the world (I’ve seen and treated the “poor” in India, Mexico, and the Phillipines).
I too am bothered that “In the current world of healthcare, we are fundamentally financially advantaged by promoting a state of unhealth among our patients.”  I am equally bothered that healthcare costs are amplified by a litigious environment that forces medical practitioners to order more tests to cover themselves.
Paying doctors less, even 40% less, isn’t enough to decrease Medicare spending substantially.  The problem is that there are less in the workforce to support the growing number of Medicare beneficiaries as the Baby Boomers retire.  The way Medicare is structured, the current workforce pays for the retired Medicare beneficiaries’ benefits.