The Razor

David Gerstman has an interesting piece up at Legal Insurrection about the IT panacea for Obamacare. He notes an op-ed by Thomas Friedman that received an endorsement by Health and Human Service Secretary Kathleen Sebelius that paints a glowing picture IT investments made under the act will have at providing better and cheaper medical care. Gerstman then follows up Friedman’s breathless piece with another that asks a simple question, if the impact of IT on health care is so wonderful Why Is Your Doctor Typing? Forbes’s Steve Denning writes about his experience at his doctor’s office where he watches his doctor typing on a computer during his exam.

Surely, I said, computerized medical records generate benefits. They are easily retrievable. They can be transferred from one practice to another and accessible to the many different service providers—hospitals, laboratories, specialists, radiology and so on—that might be involved in any one patient.

“In theory, perhaps,” he replied. “But in practice, it’s a horrible and costly bureaucracy that is being imposed on doctors. I spend less time with patients, and more time filling out multiple boxes on forms that don’t fit the way I work. Often I am filling out the same information over and over again. A lot of it is checking boxes, rather than understanding what this patient really needs.”

What about retrieving information? Isn’t that easier?

“Again, in theory, retrieval should be easy and quick,” he said, “But you can’t flip through these records the way you do with a paper file and easily find what you want.

I mentioned the articles to Dr. Wife and she said, “The only thing EHRs have done is make it easier to read a doctor’s handwriting.” Since the US is projected to spend $6 billion on EHRs by 2015, that’s a lot of money spent trying to make up for the failure of primary education to teach penmanship.

Being married to a doctor and an IT professional specializing in “big data” in the financial industry, I have watched the Wife’s experience with various EHRs with levels of amazement and dismay. It’s as if the lessons learned by the financial industry in the 1990s, such as poorly designed software that is incompatible with other software will cost more money to replace than it did to implement in the first place,  have been completely lost by the lemming-like rush towards electronic health record (EHR, also known as electronic medical records EMR) systems.

The basic problem is that EHRs are not designed to suit the ways doctors practice. This is complicated by the fact that the way doctors practice varies between specialties, an orthopedic surgeon doesn’t practice medicine the way a primary care physician does, and by the additional complication that how doctors practice varies within the same specialty, often the same office. Even the same doctor will treat patients differently depending on what he feels works best for each patient. Yet these variances between specialties are only rudimentarily addressed within EHRs, and handle variance within specialties one of two ways, providing either a set workflow that dictates to the doctor the way she should practice, or one that provides so much flexibility that she is lost trying to get basic tasks.

The key decision in any software development is to address who the software is for and the key needs it is meant to address. Judging by the current EHR systems available none were designed for doctors. Instead they were designed for the employers of doctors such as large health systems, insurance companies and the federal government who are interested in aggregated data in order to answer questions such as “How many patients are uncontrolled diabetics?” or “How much is being spent on obesity-related illness?” These are questions which might be of interest to a doctor in general, but they are not what he’s thinking about when he’s facing his patient, say a morbidly obese, uncontrolled diabetic medicaid patient. Instead he is interested only in that particular patient’s problems. Is her agoraphobia contributing to her obesity, or is it the result of it? How can he wean her off HFCS soda and begin to move and diet when getting her into his office requires so much effort? Most of all, how can he encourage her to take an active role in her own medical care and help him treat her?

Current EHR systems will be very good at picking up his patient as an uncontrolled diabetic, and the data can be used by medicaid to threaten to cut his reimbursement for her treatment as is under discussion to control health care costs. But his patient’s needs and his attempts to deal with them will be lost in the sea of data the EHR generates because current systems are modeled on existing software developed in the financial industry which was the first to successfully integrate the technology with its existing business. Even that integration wasn’t painless, occurring over decades after many fits and starts, adoption of dead-end technologies and gargantuan piles of wasted money.

A key difference between the medical and financial industries is in the nature of the data itself. Financial data is transactional, meaning that money is traded for a good. Transactional systems are repetitive. For example, a store will sell a loaf of bread for $2.59 to every person who comes into the door and asks for it, but a doctor seeing a sore throat today knows 99% of the time her patient likely only has a viral condition, and that remaining 1% can present with a sore throat but have much more serious, perhaps even fatal, underlying conditions. Doctors are taught in medical schools to “think horses when you hear hoof beats, not zebras,” but the problem is that in reality zebras are not limited to the Serengeti Plains: they are mixed in with the horse. So while a doctor should think horses when he sees an 8 year old with a high fever and sore throat, he always must rule out he’s hearing a zebra. This is why when you see your doctor complaining of head and neck pain she makes you touch your chin to your chest: doing so rules out meningitis, a rare but very serious infection, a zebra running with horses.

The equivalent of this repetition and poor data is handling would be going to the store and buying a loaf of bread with your debit card. This bread would be tailored to your specific needs on site. Prefer no crusts? The crusts would be removed. Like thicker slices? The store would slice the bread to your exact specifications. The cash register would report the sale to your bank via fax. A person at the bank would read the fax transaction and key it into the bank’s debit card system which would then debit your account for the payment to the store. Since the store’s financial records are kept at another bank, your bank would then email the credit to the store’s systems, and someone at that bank would open the attachment, read it and add the amount to the store’s bank account. Such a transactional system would be costly to run, inefficient with the same task performed multiple times, and time consuming. A similar system already exists today with check processing, but that is limited to a handful of data elements such as the bank, amount paid and the account number of the person writing the check, and the name, the account number and bank of the payee depositing the check. That’s six pieces of data that costs banks billions to process every year. Banks hate checks which is why they have backed the current system of debit cards working to replace them.

From a physician’s perspective, what should an electronic medical records system do? It should provide her with the treatment plan from the previous encounter. Most systems hide this information from a doctor, making her search for the notes from the last visit. The system should provide lab work and test results directly from the laboratory providing the test results. Currently labs do not have set data standards, and electronic medical records systems do not have the capability to receive these records directly. Instead the records are either faxed or sent via email where they are “attached” to a patient record. This is akin to attaching a picture to an email, meaning that the contents of the picture remain completely unreadable by the system. The email system doesn’t know if the picture is a snap from your trip to the beach, whether its of a sunset or a personal portrait. Data in a picture or as commonly sent PDF format cannot be read and translated into a data record directly. Instead either the doctor, mid-level or medical tech must look at the results in the attachment and physically key them into the system.

Dr. Wife tells me her current system, one of the top used in the US, can only report weight and BMI results from last visit. Lab values and other pertinent information is hidden in attachments or non-indexed patient notes. Prior to the EHR she would open a patient’s chart and look at the lab result for a patient’s hemoglobin a1c result. Since the labs were in a separate section of the paper chart she could open it up then flip backwards through the stack to immediately find the results of previous tests. Similarly she could open the chart and see the notes from the patient’s last visit to see what recommendations she had then, or flip back further to see how the patient’s condition had changed with time. To do this in her current EHR is much more difficult than flipping through pieces of paper. Instead she has to search for and find lab result attachment which may not only be located in the lab result folder, but which may have been filed mistakenly by a medical tech into the fax folder because the lab result may have arrived via fax, and was scanned and added as a patient communication. Since the information is not indexed, there is no way for the physician to type in a search box “hemoglobin a1c” and have all documents that contain the phrase pop up. Instead she has to open each attachment to determine what it is and whether it’s the lab result she is looking for. Since EHRs are rarely known as fast and responsive, opening each attachment takes 5-15 seconds depending on size and EHR file complexity, making a search which would have taken three or four seconds flipping through a paper charts several minutes to complete. When a doctor is allotted 15 minutes per patient, anything that makes a doctor’s job harder for no benefit to him or his patient whatsoever will not be appreciated. Yet hospital administrators and software companies wonder why medical practitioners loathe electronic medical records systems?

Here’s what Dr. Wife described as her dream medical records system. First, the entire encounter would be recorded to protect her from future litigation or in case anyone needed to review or document anything from the patient encounter later. Next she would be able to choose from a set of predefined dropdowns or checkboxes the treatment plan for the patient. Lab values would be available on the right side of the screen, and she would be able to click on any one of them to see details or trends. These would be automatically populated by the labs themselves without any input from the doctor or practice staff, and could be signed off by the doctor simply by clicking the value. It would be a simple app that would run on an iPad. Suri would be used to transcribe a brief note after the visit, which would allow Dr. Wife to spend more time with her patients and doing what she is paid to do, diagnose illnesses and develop treatment programs, instead of typing, filing and other busy work skills that is so devalued in today’s workplace that much of it is offshored.

Another alternative would be to hire scribes, medical technicians who are trained to enter data into the EHRs. Many optometrists who must use their hands and eyes in concert use scribes already to notate lens dimensions and other key patient facts, so their presence in the exam room wouldn’t be completely new. Such positions would pay $12-15/hour with benefits, about what medical technicians commonly earn today, and would offer advancement thanks to the coding skills and familiarity with the software developed with experience. Of course adding a scribe for each physician would increase personnel costs, but ask yourself, does it make sense to pay someone $75 an hour to do a job that can be done by someone making $15 an hour? And from the patient’s perspective, would they rather pay an extra $4 a visit to have the undivided attention of their doctor for 15 minutes instead of watching him divide his attention between them and his computer?

 

This is surprising, even to me. Maybe it’s because I still have a left0ver Socialist streak in me from my liberal days when it comes to health care.

So, what did the Oregon study authors find? They found no statistically significant difference in elevated blood pressure (1.33 percent less incidence in Medicaid vs. control, p=0.65); high cholesterol (2.43 percent less than control, p=0.37); high HbA1c (0.93 percent less, p=0.61); or Framingham risk score (0.21 percent less than control, p=0.76). According to the p values, the blood pressure result has a 65 percent chance, the cholesterol result a 37 percent chance, the HbA1c result a 61 percent chance, and the Framingham score a 76 percent chance of being statistical noise. Again, statistical significance requires a p value of less than 0.05.

I think it’s critical for those of us who tend to be political ideologues to try to act based on the evidence and not on our beliefs whenever possible, to maintain a balance between completely closed minds and those that are so open our brains fall out. It isn’t easy, and we’re only human, but we need to try.

Update 5/22/2013: As Julianne points out in the comments, Debbie Gentile-Abbood, Dr. Wife and I are all wrong when it comes to insurance coverage. The Women’s Health and Cancer Rights Act of 1998 mandates insurance coverage for the preventative removal of the breasts as well as their reconstruction. I have confirmed this here and here. I still haven’t been able to confirm whether Medicaid/Medicare covers these procedures, but with the law on the books I’d be surprised if they didn’t. Given the daily battles Dr. Wife faces with the insurance companies, and my cynicism towards anything that stinks of corporate or bureaucrat involvement in healthcare  we both assumed such coverage was not available to women. In this case, I’m very happy to be wrong. I know too many women who have been cut down early by the disease, and if there’s any chance of preventing it I’m all for it.
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A New Jersey teacher has taken issue with Angelina Jolie’s decision to remove her breasts before contracting breast cancer. Evidently Jolie tested positive for the BRCA gene mutation that makes one likely to develop breast cancer and had mastectomies before the cancer developed. Debbie Gentile-Abbood says “It upsets me… That’s good for her; she’s got the best health care and she’s got money. She doesn’t have to worry about taking off of work.”

I discussed Jolie’s decision with Dr. Wife who said it was a smart idea – if you had the money. She pointed out that a positive BRCA mutation test would likely not convince an insurance company to cover the cost of the  radical mastectomies without evidence of cancer beforehand, and they would definitely not cover the reconstructive surgery Jolie underwent at the Pink Lotus Breast Center, considering it purely cosmetic. While many have commended Jolie for her courage to face a positive test and then act upon it, her actions seem less commendable for those of us who struggle getting tests pre-authorized, or writing letters to insurance companies on behalf of patients whose life-saving medicines aren’t covered in the company’s formulary. Gentile-Abbood won’t even take the test because doing so would put her family into a predicament caused by a positive result. Get the life-saving surgery and ruin the family financially, or play the odds and hope she doesn’t develop cancer. It is an appalling choice, but one that is faced every day by hundreds of women nearly all of whom lack Jolie’s means.

I don’t begrudge Jolie for her decision, but I don’t laud her either. Instead I would hope that cancer detection and treatments improve so that all women regardless of their economic background could live life without fear. Now that would be truly worth noting.

Measles cases have soared in the UK, making it second in Europe behind only Romania in the number of cases. Last year the UK had 2,000 cases and so far this year it has had 1,200, putting it on track for another record breaking year. Of those sickened, about 20 have been hospitalized with serious complications including pneumonia and meningitis. In 1998 a paper published by Andrew Wakefield and others suggested there was a link between the measles vaccine and autism. As a result, measles vaccination levels plummeted in the UK, from 90% of children down to 54%. The measles epidemic now hitting the UK is a direct consequence of this failure.

I had a child when the scare hit, and I sympathize to a degree with the parents who thought they were doing right by their children by avoiding the vaccine. The parental instinct is to protect your child, and exposing him or her to dangerous agents intentionally, trusting faceless authorities to have done their due diligence and provide a safe vaccine isn’t easy, especially while no vaccine has zero side effects and every instance of those who did experience them gets press while nothing is written about those vaccinated and exposed to measles who were protected from the disease. Wakefield’s paper and the press he received from it fed into a natural suspicion people have for authority. Skipping the vaccine seemed sensible, especially since doing so had no immediate effect as herd immunity offered some protection for the unvaccinated.

Around my hometown of St. Louis there are several high schools and colleges run by Christian Scientists, a religious sect that believes in the power of prayer instead of the science of Medicine. While this may seem quaint or irrational to those of us in the 21st century,  at the time Mary Baker Eddy founded the group in the late 19th century Germ Theory had yet to become orthodoxy in Medicine and it wasn’t until the 1920’s that going to a doctor offered any benefit as opposed to staying at home. In fact hospitals at the time were good places to get sicker. Students at these schools are not vaccinated, and measles outbreaks are common and deaths from the disease are not unknown. Either God had an ax to grind with the Christian Scientists or measles vaccination was a pretty good idea. Perhaps the Brits would have benefited from the presence of this sect on their territory to see what happens when children aren’t vaccinated, but it’s doubtful. The specter of Autism is pretty powerful, especially when authorities have been wrong so often in the past.

But in this case they weren’t wrong; Dr. Wakefield was, and kids are paying the price for his mistake and their parents’ bad decisions.

 

I mentioned to the Wife that a pharmaceutical company has come up with new a drug to help post-menopausal women have less pain during sex. She said she’d rather see a pharmaceutical company come up with a drug that made old men attractive to young women. My Wife the comedienne…

By the time most of you read this the outcome of tomorrow’s election will be known. Regardless of who wins America’s health care system is still a wreck and closer than ever to the river catching fire point of no return where revolutionary change is inevitable – and even welcomed by some including me.

Recently a local non-profit hospital announced changes to its health insurance plan as it has every fall for years. With each announcement its employees inevitably pay higher premiums for a higher deductible that covers less. It’s a situation that employees in the private sector are familiar with, at least those that work for companies that are large enough to provide access* to health insurance.

To set the stage of the current benefit situation requires a quick review of recent history. Earlier in the past decade the hospital underwent expansion, adding scores of beds and a complete revamping of the ER. It also went on spending spree, buying up private practices and recruiting doctors to the area to open new ones. I’m not sure what drove this expansion. The hospital sits in one of the poorest areas of North Carolina that has for decades suffered high unemployment and increased dependence on government programs such as Medicaid at a time when payments to providers by Medicaid have been cut. Word was that there was a generation of doctors planning to retire, and that may have influenced the hospital’s plans. But the declining stock market and insurance reimbursement cuts meant that many of those physicians are still practicing today because they can’t afford to retire. In addition, the hospital competes with other rural regional hospitals less than 30 minutes away, plus the cancer, pediatrics and state-of-the-art trauma centers at Wake Forest and Baptist in Winston-Salem less than an hour away. The result of this expansion is a massive overhang of debt, a tiny patient census, plus the massive drain caused by too many providers chasing a decreasing pool of privately insured patients.

The HR department had assembled some of the hospital staff for a benefits presentation. As the changes sunk in the audience turned hostile, shouting at the presenters and demanding that the plan be rescinded. The HR representative took the podium and reportedly said, “Y’all are lucky we provide health insurance at all.”

She had a point. Starting in 2014 the hospital could opt out of providing access to health insurance and pay a penalty for each employee. I’ve looked around to determine what that penalty is (it’s $2k for small business owners for 50 employees or less but I haven’t been able to find it for companies with more than 50 employees), but if the cost of providing access is less than that penalty the hospital could save money by paying the penalty rather than offering access to insurance. Paying the penalty would not only save it the costs of subsidizing  insurance, it would also reduce administration expenses because administering the payment of a variable health insurance payment every paycheck is a lot more expensive than simply paying a flat penalty once a year to the IRS. Knowing what I know about back-office operations of large companies, the cost of administering health care is likely a significant chunk of that $2000 penalty per employee, so such a fine would have to be double or perhaps triple the small business tax for it to deter ending health coverage and dumping employees into the public pool.** If I were the CEO of the hospital it’s an option I’d consider as many CEOs of companies are doing. Expect this number to rise over the coming months before the provisions go into effect in 2014.

In an economically depressed area the hospital, being the area’s largest employer has the economic upper hand when it comes to lower-skill staff. But the same is not true of its physician assistants, primary care doctors and highly trained specialists. These people are also employees and notice when their insurance premiums go up, but have a much more mobile, in-demand skill-set than medical assistants, orderlies and the like. Working in a rural setting isn’t very popular among these groups to begin with, which is why rural doctors are supposed to earn more than their urban and suburban peers. When that premium disappears, these highly-trained professionals will disappear too, voting with their feet and moving to more lucrative positions elsewhere. Doctors are human; they get sick and need treatment, and when their co-pays on medicine rise to $50 per prescription per month, they notice it. Rural charm only goes so far and unfortunately can’t be used to pay down $300k of student loans. Doctors aren’t happy with the current system as providers, and when they aren’t happy as patients either you know the system is screwed.

But people have been predicting the doom of the American health care system for at least 20 years since the HMOs appeared on the scene and were supposed to reign in costs, and we all know how well that worked. I have opposed Obamacare since its inception, but the more I examine the legislation the more I believe that it may in the end be “good” for the American economy in the longer term by bringing about the end of the American health system as we know it and allowing us to start from scratch.

The Paranoid wing of the Obamacare Opposition believes this is what Obama intended all along, that expanding Medicaid while cutting reimbursements to doctors and at the same time driving companies out of providing access to health insurance the President would wreck the system to the point where people would be clamoring for a federal government takeover of Medicine. It’s not a bad idea if it wasn’t for the fact that a) it requires a complex game-plan built using information that could only be predicted in retrospect (had Ted Kennedy not died chances are Obamacare would have been much more socialist), and b) the government is broke bailing out Obama’s well-connected friends the rest of the Economy that the only way to do it is it to kick Zimbabwe off their printing presses and print dollars like the North Korean Army on a methamphetamine binge. Far more likely that Obama handed the task to Nancy Pelosi and Harry Reid so that he could play golf and read glowing pieces on his greatness in Rolling Stone and Vanity Fair, and that the Democrats made sausage out of their hopes and dreams distilled from liberal utopias in the states of New York, Illinois, Massachusetts and California. Since these states are all now circling the drain financially a federal government takeover of the health care system is impossible. It’s a shame because laissez-faire libertarian I may be, I have in the past argued for socialized medicine. The citizens of Japan paid for the birth of the Kid, and since they nearly shot my father dead in a foxhole in the Philippines during the War I’ll consider us even. The Dean’s World’s archives are scrambled so all traces of these arguments are wiped out, but I still believe that prior to the massive federal takeover of the economy caused by the financial meltdown in 2008-09 a sound argument could have been made for socialized medicine. Not so today, and definitely not by me.

Obamacare has forced us to the end of the American health care disaster. Employers will soon quit the insurance access business, forcing people to purchase insurance from the government. For the first time they will know how much they are being paid by their employers since their benefits package won’t contain more than a few worthless baubles and trinkets. Transparency is good. As a contract worker I know exactly what my skill-set is worth, something that a full time employee does not. I can then make decisions about my future that are grounded in reality. Obamacare will expand the rolls of Medicaid, forcing millions into a program that providers lose money on. At my dentist’s office I was paying my bill when the phone rang. The receptionist picked up the phone, listned then told the caller that the office no longer accepted Medicaid patients. There was another pause and the receptionist recommended the caller contact the county health department. The experience of the caller will not be atypical as health care providers “go John Galt” rather than lose money by treating Medicaid patients. This will increase the burden on the states who will then go cap-in-hand to the federal government which is $16 trillion in the hole. By 2014 when Obamacare goes completely into effect it will probably be closer to $24 trillion. Those printing plates at the Fed better be made of titanium because they’re going to be getting a workout. Maybe they can hire the North Koreans to help. Of course by then the Norks will have moved on to printing something of value, like yuan.

The collapse of the American health care system will be nasty, brutish and hopefully short, and we will have President Obama to thank for it. What comes afterward is anybody’s guess but whatever does it has to be better than this mess we are in. For that no matter what happens tomorrow, Obamacare opponents like me will owe President Obama a debt of gratitude as we man the barricades and hoist the flag of revolution over the land.

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*Let’s get something straight: Hardly any employers provide free health insurance these days. What they provide is access to group plans which they subsidize to a degree, something that mystifies my European readership (all 3 of them). The tie between access to health care and employment puzzles me too. Why the tie? Why aren’t we tying car insurance or life insurance to employment too?

** It just dawned on me that the cost of the penalty to avoid providing insurance will factor into the benefits offered the employee. Having worked for businesses large and small, I know a thing or two about how jobs are created. When a company decides to hire, it sets a budget for hiring that employee. That budget will include salary and the cost of all benefits. So if a firm budgets $50k for a position, the highest offer it will make to the employee will be Salary + Penalty=$50k or for a small business, $48k + $2K=$50k. So in essence the employee pays the penalty by not receiving the full $50k s/he would if Obamacare not been enacted. Existing employees may also face the prospect of not only having their insurance dropped, but having to pay the resulting penalty themselves. Irony… Mmmm…

In general, if you are hauling around cash in garbage bags, chances are you’re doing something that is going to send you to jail.

From Medscape (free login required):

Prosecutors say the physicians prescribed a standard “cocktail” of controlled substances — specifically, oxycodone and alprazolam — on an assembly-line basis without obtaining prior medical records, ordering alternative treatments such as physical therapy, or referring anyone to specialists. The clinics also dispensed the prescribed pain pills and accepted only cash or credit cards as payment to avoid the scrutiny of third-party payers. The cash was hauled to the bank in garbage bags.

The docs earned more than $1 million a year but now face life in prison. 7 other doctors received prison sentences up to 17 years behind bars.

Rot in hell, boys and girls, rot in hell.

Bloomberg has an article up today about the student loan bubble. It doesn’t mention the student loan bubble directly, and instead focuses on the predatory lending practices by private lenders on students (Students Pay SLM 9.25% on Exploitative Loans for College). Expect more of these articles as Democrats like Dick Durbin try to whip up support for a student loan bailout.

The article bothers me for several reasons. First, the title. I realize that the reporter Janet Loren is not responsible for this, but I would hesitate to call a loan “exploitative” at 9.25% while federally backed loans are currently 6.8% (Stafford) and 7.9% (PLUS).  The article highlights the experience of  Mirella Tovar, a 24 year old graphics designer who amassed $98,000 in debt to private lenders now making $730 a month part time as a waitress. The interest rate on her debt is 10.25%.  The difference federally guaranteed loans and private loans is only $22,000 ($135k vs $157k). We are not talking loan shark rates here. Loren hedges a bit, writing, “private lenders feature mostly variable rates that can be more than twice what some people pay in the U.S. program,” – some people being those who acquired federally guaranteed loans prior to June 2006 when rates were half of what they are today. Ms. Tovar started school after those lower rates had expired in June 2006.

Secondly, it’s not just the lack of credit history that affects the interest rate students pay. Loren fails to mention that federally guaranteed loans cannot be discharged under bankruptcy while privately financed loans can (please correct me if I’m wrong here.) Shouldn’t private lenders be allowed a higher rate of return to balance this risk?

Finally, the Bloomberg piece suggests that Ms. Tovar would have been better off with federally guaranteed loans, “I tell them to take private loans as a last resort,” she said. “I wish someone would have told me that.” But then Loren does not mention that with federally sponsored loans, Ms. Tovar would not have been able to amass $98,000 in debt, because federally sponsored loans have a $31,000 cap.

My wife graduated medical school in 2006 with $210,000 in federally guaranteed debt. The word “doctor” conjures up dollar signs to some people, but the average salary of a family doctor is $130-150k which isn’t much when your minimum loan payments are $25,000 yearly, and taxes on that amount add an additional $8,000 making it roughly $33,000. By the time we pay off her loans in about 10 years, that $210,000 will have cost our family over $350,000 including taxes. Every month I pay the bill it’s not easy, but we chose this path and in the wife’s case I believe the investment has been worth it.

Is a $98,000 investment in Ms. Tovar’s career as a graphic designer worth it? The fact that she is working as a waitress leads me to believe not. But I happen to know several graphic artists who have built successful careers over the years and would be happy to put the Bloomberg reporter in touch with them for their perspective. Ms. Tovar needs to get in at the ground level of her field, and will likely have to move away from home to do it. Life entails risk, and while Ms. Tovar has proven herself to be a terrible gambler by amassing such a sum of debt, she still has opportunities to put her degree to use. It won’t be easy, but starting life as an independent adult will never be.

There is no doubt that there is a student loan bubble, but banks aren’t solely to blame. Like most complex problems there are complicated factors behind them and plenty of blame to go around. Politicians who score points by throwing taxpayer dollars around to look generous and gain votes, then write laws making it impossible for people to discharge the debt in bankruptcy. Universities which waste money on expanded facilities and questionable curricula. Parents who spend more time researching a new car instead of their child’s education choices. Students who have had everything handed to them and are shocked when the gravy train stops. Unfortunately the article missed all of that and does little to suggest a way out of this mess.

It is tempting to call for a bailout of students such as Ms. Tovar. But are you personally willing to pay for her poor career choice and financial sense? What about the millions of degree holders who took out student loans and paid them back? Is it fair to them? I put a sleeping child in the back seat every Saturday morning for a Summer to drive the wife to an early chemistry class, and waited late at night in a dodgy section of Philadelphia with him in the back for the train to arrive carrying the wife from her classes. In between I built a career to make enough money to support us while she attended school. Is it fair to us that Ms. Tovar should be saved by the federal government while we’ve been working hard and paying taxes while paying off student loans?

I opposed the bank bailouts and still do even though most economists argued they were necessary. I believe in personal responsibility whether its a graphic arts student or investors in a bank, and view the bank bailouts as creating a moral hazard where gains are privatized while losses are passed along to those of us paying taxes. While I would love nothing more than to rid my family of my wife’s student loan debt, I realize that it is our responsibility bear the consequences of our decision and what to see that philosophy applied fairly to everyone.

I have advocated the legalization of illicit drugs for a very long time. While my politics and party affiliations changed over the years, the belief that most if not all currently illicit drugs should be legalized has never wavered. Whether taking them decades ago or living the Straight Edge path for going on 12 years, I always believed that America would be a better place as a society if it legalized and regulated marijuana, cocaine and heroin.

Walter Russell Mead challenges that belief by comparing the arguments supporting legalization with the reality of prescription drug abuse. Try as I might I’m finding it difficult to argue with the points he makes. Mead writes, “Legally prescribed drugs are now regulated the way many legalization advocates think illegal drugs should be. The flourishing black market in prescription painkillers and the thousands of deaths associated with their use demonstrate that drug use will not be magically fixed by regulating currently illegal drugs. While legalization advocates argue that putting heroin and similar drugs on a prescription basis would reduce fatalities associated with their use, the high toll from overdoses of legal painkillers suggests that this argument is weaker than often believed.

The statistics about prescription drug abuse, to pardon the pun, are sobering. According to the CDC deaths from legal prescription painkillers now surpass those from heroin and cocaine combined. In 2008, 15,000 died from painkiller overdoses. In 2010 12 million Americans used legal painkillers to get high, and that year enough prescriptions were written to keep every single American stoned for a month. That’s 4x more drugs prescribed than in 1999. Today pain is the most common reason for physician visits in the US.

As with any complex issue, there is no simple solution. Until recently doctors had taken more of a “what we cannot cure we must endure” stoic approach with their patients when it came to pain. It wasn’t until the 1970s that doctors began studying pain and specializing in pain treatment and management. Progress has been slow. The foundation of pain management remains addictive narcotics with broad effects instead of the development of drugs that target specific pain. Worse, when used to treat chronic pain these medications may increase pain sensitivity. Even when pain isn’t chronic it may take months, sometimes even years for the underlying injury to resolve. If narcotics are the main treatment for pain, should we be surprised when a patient becomes addicted to pain medications?

There is a big difference between the perception of prescription pain medications and illicit drugs. Generations have been indoctrinated into viewing crack and heroin as “dirty” and socially unacceptable. It takes years for newer drugs such as methamphetamine and ecstasy to be recognized by society as a threat and subject to a mix of propaganda and truth to stigmatize the drug and curtail its usage. In the 1980s and early 1990s meth was underground and commonly used for all night cram sessions by college students and by long haul truck drivers. Now it has been stigmatized as a cheap high for rednecks a step above huffing paint. Prescription drugs have an aura of acceptability that illicit drugs currently lack but would attain if they were legalized. Legalization presents a legitimacy which in turn implies safety. People may naturally view heroin and cocaine as dangerous and consider Oxycontin as innocuous even though one can overdose on Oxycontin as well as heroin. People believe that because a drug is prescribed by a doctor it is somehow completely safe.

While it is possible that after legalization the negative perceptions of the formerly illegal drugs would remain, it is expected legalization would expand usage and abuse. Those favoring the legalization of illicit drugs need to accept this and modify their arguments to reflect this reality. One way to do this is to focus on the core arguments for legalization such as individual freedom and personal responsibility. In the case of prescription drug abuse, doctors need to recognize the danger of supplying patients with narcotics, including the likelihood that the drugs will fall into the hands of others. It is much easier for a physician to prescribe narcotics than it is to advise patients on non-medication pain management therapies such as deep breathing, meditation and exercise. Those that need more should be sent to pain clinics which specialize in pain therapy (and can be monitored closely by authorities).

People need to be educated about pain. Pain is a reality of life and in most cases such as injury it is an important component of the healing process. Dulling it at every opportunity may feel good in the short term but present long term dangers such as prolonged healing, re-injury or addiction. Similarly people need to learn the truth about pain medications. The narcotics on grandma’s shelves are just as dangerous as those being offered for sale on the street a few blocks down.

The solution for drug abuse, whether illegal or legal, is education along with treatment options offered by for-profit and charities. As far as solutions go it’s a lame one, but the alternatives such as the continued prohibition of illicit drugs and the jailing of addicts is far worse. Far better to increase awareness and encourage personal responsibility.

As a recovering alcoholic with 11 years of sobriety under my belt, personal responsibility is the one key component to wellness that gets ignored in the debate. To those sympathetic to the addict and those who take a hard line against illicit drugs, the addict is powerless to resist the drug so the addict must either be protected from his drug or kept away from it through its illegality. Hardly anyone dares tell the addict “You live in a world with your drug. You can have it and ruin your life, or not and live a decent life without it.” There is proof that addiction has a genetic component. For some it may have an epigenetic basis. But regardless of its origin, whether the addict was born that way or acquired it later in life, one is ultimately responsible for one’s own destiny, not Society.

UPDATE:
A documentary on the Oxy Express. The most chilling documentary I’ve seen in years.
An in-depth series on prescription drug abuse by the Delaware News Journal.

My wife is a family doctor working in a small rural practice owned by a regional hospital. While she has not yet been sued for malpractice she knows many doctors who have, and while the vast majority of these suits never reach court they still inflicted many sleepless nights and higher malpractice premiums on the innocent doctors. She recognizes that everything she does may have to be justified someday so that if she is forced to testify she can explain the rationale of her treatment. This is the essence of defensive medicine.

The American Board of Internal Medicine Foundation in partnership with Consumer Reports has announced Choose Wisely, an educational initiative recommending physicians avoid 45 unnecessary tests and procedures the group believes are performed unnecessarily. These include routine EKGs and Stress Tests as well as prescribing antibiotics for minor ailments such as mild sinusitis. Oncologists are also encouraged not to perform cancer screens on breast cancer and prostate cancer patients diagnosed with non-metastatic forms of these cancers.

But as the New York Times article states, these recommendations are controversial and there is fear among some patients and doctors that they will be applied too broadly. The newspaper quotes Dr. Eric Topol, chief academic officer of Scripps Health who says, “These all sound reasonable, but don’t forget that every person you’re looking after is unique…This kind of one-size-fits-all approach can be a real detriment to good care.”

As a resident of the great state that raised John Edwards to the heights of power on the backs of doctors he sued for malpractice, I’m skeptical over this recommendation for a number of reasons. Dr. Topol makes an excellent point. Those who aren’t health care practitioners may fail to understand that patients often do not present with clear cut symptoms. There is a finite number or reasons your car won’t start in the morning such as the battery is dead, the tank is empty or the ECM needs replacement. But the human body is infinitely more complex. What may present as back pain from too much Pilates can turn out to be bone cancer that had metastasized from the esophagus, as happened to my father-in-law. The chronic tickle in the back of the throat that drove my mother-in-law crazy for months, turned out to be an atypical and rare form of breast cancer. Both were dead within months of their initial complaints both were misdiagnosed by their primary care physicians, though it is unlikely in either case the proper diagnosis would have mattered much. But both cases of cancer could have been treated had they been detected early. Obviously doctors cannot perform these tests on everyone because it would take too much time and cost too much, but this decision should be left to the judgment of the doctor and not interfered with by the government, an insurance company or a non-elected body such as the American Board of Internal Medicine Foundation.

These recommendations will no doubt be cheered by insurance companies and the government (since Medicare, Medicaid and Obamacare make the government a de facto insurance company I’ll lump it together with the likes of Kaiser Permanente and Blue Cross for the rest of the article.) Insurance companies can now refuse to pay for these tests or at the least requiring doctors jump through time-consuming and money-losing hoops such as requiring pre-authorization to do them. The article claims that as much as 1/3 of the $2 trillion spent on health care in the USA is unnecessary, so imagine the savings to their bottom lines these companies will enjoy by cutting nearly $700 million from their payments. The problem with this figure is that it’s like the old saying about half of marketing dollars being wasted, but no one knows which half. Because it is impossible to accurately determine which person needs a test and which doesn’t it will be impossible to reap the savings hinted at in these recommendations.

Doctors are taught the cliche, “When you hear hoofbeats, think horses, not zebras.” The problem is in the real world zebras aren’t limited to the Serengeti, they are mixed in with the horses here. And doctors are blind. The practice of medicine remains an art where such non-quantifiable processes as “intuition” still play an important role. A doctor might be presented with a healthy young man in his prime with no signs of heart problems, but something might trigger his intuition to call for an EKG. While rare, young people do make the headlines when they drop dead of cardiac arrest caused by a previously undiagnosed heart condition. The physician suspecting he might have a patient with an undiagnosed heart problem will have to fight to get the insurance company to pay for the EKG, skip the EKG and console himself that the young man is healthy, or do the test for free.

Imagine the doctor finds himself in the dock, facing an attorney hired by the family of his patient. “Why didn’t you do the test, doctor? It’s a simple test you could have performed in your office that would have saved the life of my client’s son. Yet you didn’t. Why?” The American Board of Internal Medicine Foundation will not be on the stand, the doctor will, and parroting off the American Board of Internal Medicine Foundation’s recommendations will not play very well to the jury.

So to avoid that possibility, the doctor will either have to fight the insurance company to pay for the test or will have to perform it gratis. Either way the physician is the one left bearing the responsibility for these recommendations. And 99% of the time the doctor will find that the patient’s heart is fine, in which case outside groups like Consumer Reports will wail about unnecessary tests. But the doctor knows that without tort reform she must do everything to protect herself including ordering tests which may seem considered medically unnecessary but will protect her in court. The tests might be medically unnecessary but until there is tort reform they will be legally necessary and will continue to be performed.

I am a supporter of Herman Cain, but I am a bigger supporter of the effort to defeat President Obama in November 2012. With that goal in mind I believe that it is critical to do what the Democrats failed to do in 2008 and vet our candidate thoroughly. At one of the debates (I’ve seen every one and honestly they start to blend in to one another) Cain led off with his fight against colon cancer but otherwise no one has mentioned it.

Until October 13th when the Washington Post ran a story “Cain beats odds against surviving colon cancer.” The story explains how in 2006 he was diagnosed with Stage IV colon cancer that had spread to his liver. He underwent four treatments of chemotherapy then had a third of his colon, 70% of his liver and 48 lymph nodes surgically removed followed by another round of chemotherapy. Cain believes he is cancer free, and in his autobiography writes that he is “Cured!”

In the interest of selecting the strongest candidate to beat Obama in 2012 Republicans have to ask, “Is he?” because if they don’t the Democrats will raise the issue after he wins the nomination.

Colon cancer is considered to be Stage IV after it has spread to other places in the body. Usually it metastasizes to the lungs and in Cain’s case, the liver. In most cases, removal of the tumors along with chemotherapy are not curative, but there are cases where they are. In his book Cain claims that he has been monitored by doctors and that the cancer hasn’t reappeared since the 2006 diagnosis; based on his being cancer free for 5 years, he writes that according to his doctors he is cured.

I am not a cancer specialist, but I do have access to the Internet and what I’ve found leads me to believe that what Cain writes is a little optimistic. Colon cancer can be cured, but it also can reappear years after treatment. It can then be treated again using chemotherapy and surgery, but it is still a big deal when a future Commander in Chief is the subject. What are the odds that Cain will remain cancer free? Not 100%, and you can bet that the Democrats will use the battle which Cain is rightly proud of fighting and winning to sow fear, uncertainty and doubt over his condition once the GOP has settled on him. It will be subtle at first like the Washington Post piece, with later reports from doctors less sanguine about Cain’s prognosis gradually creeping in to stories. Then there will be the inevitable stories about the importance of his running mate although little fuss was ever made about Obama’s selection of Joe Biden as his, possibly the least intelligent VP pick since George Bush Sr. chose Dan Quayle (although to his credit, Quayle has matured a lot over the decades whereas Biden is still a garden variety moron). In the heat of the campaign battle a year from now I would expect there to be continuous health statuses discussed daily, with every cough a symptom of lung cancer and verbal gaffe the result of a cancer metastases to the brain.

Again, I am not a cancer specialist, but I have watched elections unfold since 1972 and I know that every possible weapon will eventually be used. Nothing is left on the table. Ever. Cain supporters and Republicans need to open this line of inquiry into their candidate today while most Americans aren’t paying attention to immunize and strengthen Cain’s candidacy if and when he does become the GOP standard bearer.

 

 

This article first appeared at American Thinker, September 30, 2011.

A recent study in the journal “Health Affairs” compared physicians in the United States with those in Europe, Australia and Canada and concluded that higher physician fees, including those by primary care physicians (PCPs), were the main reason for escalating health care costs in the US. In short the authors of the study Miriam Laugesen, an associate professor at Columbia University, and Sherry Glied, appointed in June 2010 by the Obama administration to the position of assistant health secretary for planning and evaluation, believe doctors are overpaid.

In a statement after the study was announced, Glied tried distance the Obama administration from the study, saying that the study did not reflect the administration’s views. Laugesen has targeted physicians in the past. In her 2009 paper “Siren Song” she compared Congress to Ulysses as being unable to resist the siren song of physicians groups. Glied’s work has been no less controversial, penning a study that found “substantial racial/ethnic disparities in satisfaction with care,” implying physicians were racists.

I presented the study findings to the head of a non-profit hospital. S/he believes that this study is the first shot by the Obama administration in a war against physicians to cut health care costs by cutting Medicare payments. There is currently a bill in Congress recommending a 29% decrease in Medicare physician fees, and s/he believes that the Obama administration will use this study to negotiate a “compromise” cut of 10-15%. Since private insurance increasingly use the Relative Value Unit (RVU) method to determine their own reimbursement schedules, this would have the effect of cutting payments not just for Medicare but to private insurance payers as well.

It is ironic that doctors would find themselves targeted by the Obama administration. The American Medical Association endorsed Obamacare, much to the dismay of a large portion of its members. Although the Association tried to walk back its support two years later, the AMA finds itself in the sights of the administration that got what it needed from the group, and Republicans who view the organization as providing the cover the bill needed at the critical time when it could have been killed. Suddenly doctors find themselves with few friends on either side of the aisle.

Laugesen and Glied’s study design suffers from errors of omission and faulty assumptions although it was extensively cited by the press. First, it didn’t mention the cost of malpractice insurance, which averages $12,500 per year for primary care physicians but is tiny in countries with national health systems that do not award large payouts.. Second, it called the cost of medical school in the US “negligible”. Medical school abroad is often free but American doctors graduate  $180,000 in debt that will cost each $400,000 in taxable income to pay off over 15 years after the loan is capitalized and taxes are included. Next the study compared Medicare payments with private insurance payments, but didn’t consider Medicaid which pays on average a third less than Medicare for the same treatment.

What is the average pay for a primary care physician in 2011? Statistics vary. It should be no surprise that health care personnel placement firms report higher salaries since placement firms encourage lucrative starting salaries so that they can get a bigger cut after they place a doctor. But this overstates salaries since most doctors earn these starting salaries for a fixed time and are then placed on productivity – whereby their salaries fluctuate depending on the number of patients they see and the procedures they perform in a quarter as translated into RVU’s. The Bureau of Labor Statistics reports a median income for family and general practitioners in 2011 of $163,510.

If salaries are the main driver of escalating costs shouldn’t they escalate? A 2006 study by the Center for Studying Health System Change reported that in 1995 the average salary for a primary care physician was $135,036. By 2003 that figure had risen to $146,405, but adjusting for inflation by using 1995 dollars, the 2003 salary was $121,262, a 10.1% decrease in just 8 years. Translated into 1995 dollars, the BLS 2011 median income of $163,510 becomes $110,299. Primary care physician salaries have actually declined over the past 16 years. Even Laugesen and Glied’s fantastic average of $186,582 is the equivalent of just $125,862 in 1995 dollars, below the 1995 average of $135,036 reported in the 2006 study (see chart below).

According to the Department of Health and Human Services in 1995 the per capita national health expenditure was about $3,950. In 2009 the per capita expenditure was $8,086 – $5,744 in 1995 dollars. Health care costs are soaring – that’s a rise in 14 years of 45% beyond inflation, but Laugesen and Glied’s conclusion is wrong. How can primary care physicians be the main drivers of higher US spending on health care when their earnings have fallen not risen?

Medicine is a business, but for some reason doctors are penalized when they begin to treat it like one. As the high ranking member of the non-profit hospital states, “Relating the income to the costs born by physicians is a silly comparison….That isn’t ever done for the lawyers is it?”

Doctors aren’t to blame for the health care system mess, but they will soon find themselves held responsible by an administration that got what it needed from them two years ago and now finds them expendable.

It is an undeniable fact of life that mountains are always beautiful. Dr. Wife’s beeper had gone off at the Waffle House so she made a quick cell phone call. Instead of leisurely finishing off our breakfast served by a harried elderly waitress, we headed up the two lane state highway through the foothills and up the Blue Ridge mountains to the hamlet of Sparta where a woman’s death certificate waited to be signed.

She had been a woman in her early 60’s from France who had met a GI and returned with him to the county in North Carolina where he had been born. There she settled down to raise her children and later, her grandchildren. Her husband had passed away years ago, leaving her alone in her small cottage nestled in a mountain valley. After the decades spent living in the United States she had never managed to rid herself of her French accent, which, when added to the southern accent she naturally became accustomed to through the years, made her speak English with an Acadian or Cajun-sounding accent. Dr. Wife loved the way she spoke.

Dr. Wife met her patient for the first time in July after she came to her with back pain in her tailbone. While talking with the woman, Dr. Wife became suspicious that the pain was more than a bruise or muscle strain as had been diagnosed elsewhere. Such pain doesn’t linger or worsen over a period of months as the pain had for her patient, so she ordered a CT scan. At first the woman’s insurance company refused to cover the procedure, forcing Dr. Wife to justify the procedure in a lengthy phone call with the insurance company. It relented and the procedure was done.

The CT scan was clear: her body was filled with cancer. It cancer had begun in the lung and metastasized to the liver and later to the bottom of the spine. In fact it had eaten away a large hole in the woman’s coccyx, and the Wife was furious because the woman must have been in terrible pain. People in the mountains are different, she says; they don’t come to the doctor unless they are extremely sick and they never ask for medication even when they are in pain. Life in the mountains is beautiful, but it is far from easy, so the people that remain there are hardier than most. They are extremely tough mountain folk that have lived there for generations, and even though her patient had been born in Europe, she had arrived and over time gradually become one of them.

After signing the death certificate at the funeral home, we stopped by her home. A “Slow – Funeral” sign greeted us as we neared it, and a large cross made from white carnations hung on the porch. There a few weeks ago the woman had stood with the Wife, telling her “I am going to beat this.” But Dr. Wife knew that this cancer wasn’t beatable. I pulled up, parking alongside several other cars parked on the grass off the road. I stayed in the car with our dogs as the Wife went inside. Over the past few weeks she had grown close to the family, giving the eldest son our home phone number so that he could call with any question or concerns about his mother.

Bird feeders the woman had bought and filled hung empty of seed beneath trees losing their leaves. Little kitschy figurines of a smiling panda and fat frog stood in a garden that she had once tended, with the first weeds that had taken advantage of her weakness from chemo appearing in soil she would never touch again. Several wind chimes hung from the roof of the porch, motionless in the unusually still mountain air.

From diagnosis to death? 8 weeks.

Like many living in the mountains, she was a heavy smoker and it no doubt contributed to if not outright caused her cancer. Some might be tempted to blame the woman for her own death. After all she chose to smoke. But she didn’t choose to die. I often wonder if the excuses we make blaming the victims for their own deaths aren’t just emotional survival mechanisms to keep us from feeling. A woman is killed by her ex-husband? She should have divorced him sooner or gotten a restraining order. A cop is shot during a routine traffic stop? He knew the risks. I suppose it’s natural to develop this inner voice to keep Death at arms length and avoid being overwhelmed by emotions, but I question whether over time that distancing is healthy. Perhaps a little empathy in our lives isn’t a bad thing. If we feel we can motivate ourselves into action which in turn can lead to Death being cheated every once in a while.

With a hug from the eldest son, the Wife arrives back in the car. She raises a long strand of a wind chime with handmade brass chimes and carved wooden clappers. “She wanted me to have this,” she says, explaining that the woman knew we had once lived in Japan where the wind chime was made. It hangs on our front porch, and I hear it lightly singing in the wind that comes off the mountains the French woman called home.

I’ve been keeping Dr. Wife abreast of the controversy raging among conservatives about Texas Governor Rick Perry’s mandate to vaccinate 12 year old girls against HPV. She is very supportive of the vaccine saying “It is one of the few weapons against cancer we have,” and believes that boys should get it as well since they can be carriers of the virus, and it is not known whether the virus contributes to other male urinary tract diseases such as prostate and bladder cancer.  What is known is that it prevents cervical cancer in women, and may protect them against other cancers as well.

I have been an apologist for Michelle Bachmann, believing that she has been treated unfairly by a misogynistic press that hates conservatives. But her attempts to beat Perry down with this controversy have crossed the line from political theater into the absurd. By courting the anti-vaccine crowd she has shacked up with Ron Paul in Crazytown and shown that she may be just as loony as the left-wing press has made her out to be.

I have serious issues with Perry’s mandate. I believe the government has the right to interfere in parenting only in certain egregious cases of abuse. Being a libertarian-minded parent myself I have had my share of run-ins with ideologues who think they know better than I do what is best for my child. It is an issue that resonates in my family since my parents fought an effort in the 1950’s to force my brother to have an experimental open-heart surgery that most likely would have killed him. My father risked going to jail rather than see his son experimented on, and it was only after my brother’s pediatrician intervened on my father’s behalf that the state backed down.

So Perry’s open for some serious criticism on the mandate issue. Since the HPV virus is only sexually transmitted it’s not like he had to mandate the vaccine in order to prevent the disease easily spreading like measles or meningitis.

But what Bachmann has done is conflated the mandate issue with the vaccination issue – and here she has gone off the rails. There is no scientific evidence that the vaccine is dangerous. All vaccines have side effects and some may even cause deaths in a tiny fraction of recipients, but that risk is overwhelmed by the lives they have saved and the cases of diseases they have prevented.

I am a climate change skeptic because consensus shouldn’t mean squat in science and the data isn’t there to support the AGW theory. But I am at heart a scientist and the evidence that vaccines save lives is overwhelming. Anyone who doubts their power should visit the 3rd World and see children dying from diphtheria and mumps as I have; it’s not pretty and it’s completely preventable. Bachmann needs to walk back her statements on this controversy or risk losing the support of people like me who are Republicans AND scientifically-minded. The GOP shouldn’t become the party of ignorance, but it is well on its way if Bachmann continues this line of attack.

Assume a business day of 8 hours. For each hour a family/primary care physician can see 3 patients at 20 minutes each. During each 20 minute visit a doctor has to review a patient’s history, listen to the patient’s complaint or reason for the visit, make a clinical diagnosis on how to best treat the patient’s problem, and assess the patient for signs of any other disease process. All this must be carefully notated in the patient’s chart to track progress and to document the visit for insurance purposes and in rare cases, legal actions.

So the doctor sees 24 patient’s in a day. Assume each patient’s insurance is billed $100 for the visit. Of that $100 the doctor’s practice expects to receive (including patient co-pays) $50. 50% of that $50 is kept by the practice to pay for overhead (medical assistants, receptionists, nurse practitioners, building costs etc). That leaves the doctor $25 per patient.

3 patients an hour means $75 hour, and that equals at 2000 hours a year, $150,000. This is a good wage by most standards. The problem is that doctors don’t work 2000 hours.

As well as seeing 24 patients, the doctor is responsible for managing physician assistants and nurse practitioners. He or she is ultimately responsible for the treatments made by these mid-levels and can be held accountable by the medical board and in court for any mistakes they make. This usually means monitoring what the mid-levels are doing, reviewing their charts, and assisting with their treatment options. This supervision is completely unpaid; the doctor is not reimbursed for his or her time.

Throughout the day test and lab results from current patients arrive on the doctor’s desk. S/he must review these and sign-off on them, adjusting medications or marking for follow-ups as needed. This work is unpaid.

Each refill request made by a patient must be reviewed and signed off by the doctor. He or she is not paid for this work.

20 minutes is not enough time to adequately document a patient’s chart. A doctor will often make quick notes during the patient visit and complete the chart after visiting hours. Charts for those with complex problems and chronic conditions can take upwards of 30-60 minutes to document each visit – all done for free.

When all is said and done, a doctor will spend 8 hours with patients and an additional 4 hours on unpaid tasks, resulting in a 12 hour day. 12 hour days result in working 3000 hours a year*. At $150,000 year (the extreme high end of PCP salaries by the way – the average is more like $125,000), that’s $50 an hour. This is still a good wage, but to receive it a doctor must have done the following:

• Received a 4 year degree.
• 
  
• Applied to and been accepted to a medical school program. This process is highly competitive and takes at least a year. There is another year delay between acceptance into medical school and actual attendance.
• 
  
• Graduated medical school in 4 years.
• 
  
• Completed a 1 year internship.
• 
  
• Completed a 2-3 year residency.
• 
  

It is impossible to work during medical school, so those 4 years of lifetime earnings are lost. During internship and residency, doctors earn $30-35k year. Although the 80 hour week is officially frowned upon by residency programs, interns and residents continue to work these hours. For argument’s sake let’s assume a 60 hour week at $30,000. That’s $10/hour for the first 3 or 4 years of work. In my area cashiers at Wal-mart earn that, do not work more than 40 hours/week and do not have to worry about making a mistake that kills someone.

The average undergraduate finishes college with $23,200 of student loan debt. The cost of applying to medical school, something that isn’t often mentioned, is significant. Figure an additional $5-10k for school applications and interviews, MCAT test and prep, and travel. The average medical school debt is $156,456 – but this assumes the loan amount is paid back immediately upon graduation. No intern working 60 hours a week for $10 an hour can afford to pay that loan back, so the loan is capitalized during residency and soars. That $180,000 in student loan debt can quickly become $300,000 after interest is incurred during the loan forbearance. Student loan repayments are also taxed**, meaning that a physician earning $150,000 will pay 28% tax on his or her loan payments. He or is she is paying $5,600 to the IRS as well as $20,000 a year to the student loan servicing firm, thereby turning that $300,000 loan into a $384,000 one after taxes.

Just for kicks, let’s figure that into our $150,000 salary. So let’s assume loan payments of $20k yearly.
Salary***: $150,000
Taxes: -$42,000 (28% bracket – Federal only)
FICA:  -$8,796 (6.2% on $106,800 + 1.45% on $150,000)
Loans: -$20,000
Total: $79,204

And remember: that’s for 12 hour days – not 8.

One would do better as a plumber or in a slew of clerical and office jobs.

And politicians wonder why there aren’t more primary care physicians?

Anything that is free will be abused; therefore the non-patient unpaid activities by primary care physicians have exploded because there is nothing to keep them in check. Patients will not accept charges by a doctor for paperwork or prescription refills, and most doctors aren’t willing to pass on this cost directly to their patients anyway. Likewise insurance companies refuse to pay for the time spent doing paperwork viewing this as part of the original bill; yet insurance companies and Medicaid/Medicare routinely audit charges and payments made to providers, basing payment solely on the time spent with a patient and the clinical diagnosis of the ailment. Anything that strays from the norms set by the insurance company or Medicaid/Medicare auditor is immediately flagged for fraud and the practice is subject to penalty.

This raises another issue with reimbursement: Medicine is the only business where the consumer (the insurer) sets the price for the services provided. If one goes to a salon for a haircut, one does not decide the fee the stylist receives; if one did it would be expected that he or she would pay as little as possible for the service.  Doctors may bill for a procedure, but the insurer can pay whatever it believes fair. Doctors are forced to accept the payment and bill the patient for the amount not covered by insurance, or stop accepting insurance from the insurer. This is difficult to do with most private insurers, and illegal with Medicaid and Medicare.
———-

*I forgot to include after hours call. Call schedules can vary from practice to practice, with some practices requiring a physician to cover a week of phone calls every month or two to as much as once every four days demanding in-person hospital admissions. This time too is unpaid but has been left out of this analysis due to the lack of available statistics.

**Student loan interest is tax deductible only up to a cutoff of $75k or so, well below the salaries earned by PCPs.

***Primary Care Physicians are increasingly paid using RVU’s, a system formulated by Medicare and followed by many insurance providers and healthcare systems. In a nutshell this system is a productivity based system in which doctors are paid by the complexity of the visit, the skill treatment requires, and the time expected for treatment as determined by the insurer NOT the provider. Salary is commensurate with the number of RVU’s a physician bills for during a given month minus practice overhead (overhead averages 50-75%). The RVU system requires a doctor to meet his or her RVU quota in order to obtain his or her agreed upon salary; if he or she fails to meet that quota, he or she receives less than that salary.

In this respect physicians are paid more like hourly wage workers whose pay packet directly correlates to the time spent on the job. Work less and one is paid less. Similarly a physician can see fewer patients, but will receive a smaller paycheck at the end of the month.

A doctor might rationalize spending 10 minutes more per patient, believing that the time is necessary to provide decent care. This extra 10 minutes per patient lowers a doctor’s productivity by a third, and ultimately results in a similar-sized hit to his or her paycheck – bringing it down in our above example from $150k to $100k. A doctor might also take a different tact, spending 10 minutes less with each patient in order to increase his productivity by seeing 6 patients instead of 3 per hour. The problem is that the short visit limits the number of RVUs he can bill for that visit. Attempts to bill a 10 minute visit as a 20 minute visit constitute fraud and may result in criminal prosecution or loss of license. Less time spent per patient can indeed result in a higher salary but open the physician up to missed or improper diagnoses and treatments that could result in poor patient outcomes and possible legal action.