Thursday, July 23, 2009

What Obama Thinks of Doctors

Did anyone notice that President Obama seemed to be calling American physicians hucksters last night? I wouldn't have believed it myself if I hadn't heard it with my own ears. A reporter asked if he'd be willing to "guarantee" that the government wouldn't prevent patients from gaining access to particular treatments. The president said no, he would not. Then he said:

"Right now, doctors, a lot of times, are forced to make decisions based on the fee payment schedule that's out there. So if they're looking and -- and you come in and you've got a bad sore throat, or your child has a bad sore throat, or has repeated sore throats, the doctor may look at the reimbursement system and say to himself, "You know what? I make a lot more money if I take this kid's tonsils out."

Now, that may be the right thing to do. But I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change -- maybe they have allergies. Maybe they have something else that would make a difference."

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Got that?
You're "forced" to make decisions based on the fee schedule, and you're unnecessarily removing children's tonsils(!) just to make a buck. Fear not, however, because "part of what we want to do is to free doctors, patients, hospitals to make decisions based on what's best for patient care."

Well. That is quite a statement. I wonder what you all think of it: Are you indeed performing unnecessary procedures because of the fee schedule? Have you ever said to yourself something like "You know what? I make a lot more money if I take this kid's tonsils out," and then done so, needlessly? What other unnecessary and potentially dangerous procedures have you performed on children, just because you'd "make a lot more money"? (Don't worry; it's an anonymous forum.) Do you find that statement insulting? Is anyone concerned that the President of the United States thinks that this is what you do?


  1. OK, I think Obama's example was extreme (Unnecesssary surgery? C'mon). But I think the point he was trying to make was similar to what Atul Gawande was getting at in a recent New Yorker article ( Unecessary tests, scans, and procedures are contributing to the ballooning costs. More tests means more revenue. Isn't that a problem with the fee payment schedule?

  2. Bob,

    Yes, I would guess that many doctors would find it insulting to themselves.

    And then each would pause for a moment to identify (to themselves, of course) their colleagues who they know practice medicine exactly that way.

  3. Internist with no pity for surgeonsJuly 23, 2009 at 12:16 PM

    I review charts for a medical review company on occasion. An ENT doc performed a nasal reconstruction on a patient. It was an outpatient surgery, probably took 2 hours. Charge to insurance company- $16,000.

    On Mondays I work from 8 am to 7 pm and see 25-35 patients with complex medical problems- diabetes, stroke, AIDS, infections, etc. At the end of the day I look at my gross charges and they are 1/3 of what that surgeon charged for his 2 hours.

    So is that surgeon going to recommend nasal spray and allergy testing or a nasal reconstruction?

  4. I think your rhetoric is a little much:

    "...President Obama seemed to be calling American physicians hucksters last night? I wouldn't have believed it myself if I hadn't heard it with my own ears."

    Our president was illustrating an inherent weakness identified by most everyone who has studied the issue: a major cost-driver in health care is physician services being paid in a fee-for-service model.

    I think your protest ia a little too much. He was not attacking physicians, he was criticizing the perverse incentives created by our health insurance industry.

  5. I asked the AMA to respond to Obama's comments, and here's what they sent, attributed to AMA president J. James Rohack, MD:

    “As a physician, I know that physicians focus first and foremost on providing the best patient care we can within the confines of a broken health care system. Physicians are also concerned with the increasing cost of care, and need better information on which treatments work best to help patients and physicians together make better informed health care decisions. Research should guide and support clinical decision-making -- not dictate it.

    “Physicians work tirelessly for their patients, and the health system should help them do this. In addition to covering the uninsured, health system reform should repeal the broken Medicare physician payment system and improve the broken medical liability system. The private insurance market must work better for patients and physicians forced to navigate a maze of bureaucracy. Huge savings can be attained by simplifying duplicative administrative requirements for payment of insurance claims.

    “The AMA is committed to health reform this year that provides high-quality, affordable care to all Americans.”

    Well, I'm glad they cleared THAT up. This is their statement, so I'm posting it.

  6. Well, I just have to jump into the fray. I consider myself in fairly good health, but earlier this year I had an unfortunate case of gastritis. Because I am over a certain age, my primary-care doc (who couldn't fit me in) suggested I visit the ER. I reluctantly went, convinced I was suffering from heartburn. The ER was professional and thorough, and probably was following protocol. But, I walked out of there with over $1,800 in unnecessary tests and care, and a diagnosis of... you guessed it... heartburn. Now come on. The system is broke. We need to get over our intrinsic distrust of each other and come up with the beginning of a solution. Which is what our president is trying effect.

  7. So a man who smokes and has spent $1 trillion dollars that the nation doesn't have is lecturing us about how to make healthcare less expensive?

  8. The PRESIDENT (who smokes on occassion) who leads our REPRESENTATIVE GOV'T (which passed the bail-outs / stimulus bills) is facilitating an honorable and just effort to reform health insurance.

  9. I'm a gynecologist and I NEVER decide what treatment to recommend to a patient based on a fee schedule. And, I'm not sure where this idea that doctors order more tests in order to make more money. Unless you have a financial interest in a lab or imaging center then the tests you order there will not make you any money at all. Now, ordering more tests so that when the lawyers come for some frivolous lawsuit and ask why you didn't do this and that you can show you did everything possible, now THAT does happen, and what they need to do is reform medical malpractice and that would start to change.

    I'm already on my way out of the profession because I've had it. I had it years ago, but leaving this profession isn't easy (insurance tails, restrictive contracts, etc), but I'm determined. If I was making so much money, then why would I be dying to leave? The opinions of people that have NO idea what it's like to practice medicine are amazing.

  10. Goodbye, Anonymous Gynecologist. We will miss your strong ethics and defensive medicine.

  11. Bob, Did you get your journalism "shock" style from watching too much FOX? If everyone in the medical profession is so honorable why is the DEA visiting Dr. Murray's house today? Write something that engages discussion on the "real problems" of the "fee for service" payment model. From reading most of the comments it does not appear to be over your readers heads only the author's.

  12. General Internist here.
    Healthcare reform without tort reform is just crazy. To the poster with heartburn who had $1800 in ER tests. If you had a history 99% compatible with heartburn and we had reasonable tort reform the ER doc would have just given you a GI cocktail and some prilosec and sent you on your way. But because there could be a multi million dollar lawsuit if we miss a heart attack, a whole bunch of extra wasteful tests are ordered.

  13. I think Obama is just like the rest of the medical decision makers. Sits in his office and decides what should happen without having a clue how it is here in the real world of medicine whether in the office or a facility. I agree with the GYN who is looking for another profession and the Internist above that cannot do enough to cover/protect themselves from the "sue happy" world we live in!!!

  14. I am a primary care doctor seeing complex cases all day. I totally agree with the Gyn and Internist. People sitting in "high chairs" cannot see grassroot level problems.

  15. To the internist with no pity for surgeons...$16000 sounds like a lot for a nasal reconstruction. But do you know how long that surgery took, how complicated it was, how long it took to prepare for the surgery - including reviewing photos, planning flaps, mapping vessels, counseling the patient, perhaps even going to the lab to perform a mock surgery, how many hours the surgeon will spend in follow-up exams? Do you realize that the surgeon will get reimbursed no more than 30% of that fee?

    I am an ENT surgeon. I lose money every time I step into the OR, because I can make much more seeing patients in the office. If we were actually paid what we charged, without having to fight for every cent through appeals and endless paperwork, we might actually be able to have a "fee schedule" that reflects cost and worth.

    In what other business does the client get to decide whether or not or how much he is going to pay you for a service?

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