I hope you’re sitting down

Those of you with weak hearts, uncontrolled seizure disorders or a fragile belief in the innate beneficence of all humanity should probably skip this post.  Those of you made of sterner stuff, get ready for me to rock your world!

Still here?  Have you braced yourselves?  Feeling steady?  Then get ready for a heaping helping of unvarnished truth:

Doctors like to get paid.

Yes, it’s true. Even though “because I want to help people” is a pro forma required answer for all medical school applicants, we like to be paid for it.  This is (hopefully) not the sole consideration when deciding whether to enter the field, and most of us really do want to help people.  Many doctors serve a stint or two with a medical charity, and lots defer higher salaries for the sake of helping the truly needy.  However, at the end of the day we’re looking for a paycheck just like anyone else.

I will pause for a moment and let those of you who need to take a calmative run to your medicine cabinets.

A new study in the New England Journal of Medicine highlights what happens when doctors don’t get paid.

We found a disparity in access to outpatient specialty care between children with public insurance and those with private insurance. Policy interventions that encourage providers to accept patients with public insurance are needed to improve access to care.

Let me translate that — they found that doctors won’t see patients without getting paid to do so, and that public insurance isn’t paying.  Making the public insurance program one that pays will be necessary for doctors to start seeing patients with it.

For anyone who has been in medical practice for more than a month or two and knows anything about billing, this finding is blindingly obvious, along the same lines as “water — still wet!” and “children don’t like the pointy parts of immunizations.”  This quote from the article in the New York Times reporting on the study sums it up nicely:

Another physician not connected with the study, Dr. Judy Neafsey, medical director of the specialty care center at Stroger Hospital, part of Cook County’s public hospital system, said: “It’s interesting to think you even need a study to prove that. It’s pretty much common knowledge.”

All glibness aside, of course we need a study.  We cannot possible hope to change an incredibly broken system if we can’t prove that it’s broken in the first place.  And the system is certainly broken.  From the same article:

In Illinois, according to Dr. Rhodes’s article, Medicaid will pay $99.86 for an office visit for a problem of “moderate severity,” compared with $160 from a private insurer. Many doctors said they could not keep their practices going if they accepted too many Medicaid patients.

This is hardly unique to Illinois.  In the state where I used to practice, the Medicaid program got so far behind that it threatened the viability of numerous smaller practices throughout the state.  It was a major, major problem.

The problems with Medicaid underlie much of my skepticism about state-run insurance programs.  I’m philosophically in favor of states offering coverage for everyone, such as has recently happened in Vermont.  Medicaid is an integral part of the Obama health care reform plan, which works just fine on paper.  But providing “coverage” in name only helps nobody.  It does not help patients to enroll them in an insurance program that won’t pay for their care.  Doctors and hospitals won’t provide treatment if payments are chronically late or are substantially lower than they can get with other carriers.  Public health insurance programs must be appropriately funded and efficiently administered, or they’re simply going to fail.

Update:  I should have just kept on with my morning reading before I posted, because here’s another article from the Times that fits hand in glove with the other.

From New Jersey to California, state officials are bracing for the end to more than $90 billion in federal largess specifically designated for Medicaid. To hold down costs, states are cutting Medicaid payments to doctors and hospitals, limiting benefits for Medicaid recipients, reducing the scope of covered services, requiring beneficiaries to pay larger co-payments and expanding the use of managed care.

As a result, costs can be expected to rise in other parts of the health care system. Cuts in Medicaid payments to doctors, for example, make it less likely that they will accept Medicaid patients and more likely that people will turn to hospital emergency rooms for care. Hospitals and other health care providers often try to make up for the loss of Medicaid revenue by increasing charges to other patients, including those with private insurance, experts say.

Shrieking liberal that I am, I happen to think that it’s worth letting the Bush tax cuts expire in order to actually pay for the healthcare of a substantial number of Americans.  Since I know the chances of that happening with the current Congress are roughly the same as a team of leprechauns magically dropping gold into hospital billing departments, I won’t hold my breath.  But let’s not pretend that Medicaid patients will have anything like real medical insurance in the coming years.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. You’ll pardon me, I hope, for doing a callback. (I’m really a one-trick pony, at the end of the day.)

    Let’s say that you get told “nope, this check is all that you’re getting and you have the choice between cashing it and not cashing it.”

    Then what?

    Would you quit?

    If the answer is “yes, I’d quit”, if you were told “you can’t quit”, would you then see your position as analogous to slavery?

    Or is such thinking really overwrought?

    How much money do you deserve for the stuff that you do?
    Does the fact that people deserve the care that you could provide change that dollar amount at all? (Or is that already baked into the cake?)

    • Let’s say that you get told “nope, this check is all that you’re getting and you have the choice between cashing it and not cashing it.”

      Well, first of all, this already happens. That’s what managed care is all about. Insurance companies set an amount they’re willing to pay, and if we agree to accept that insurance then we agree to their terms. Medicaid doesn’t differ in the manner of reimbursement, but in the amount and timeliness.

      We also have a few other choices. We can bill patients for the difference between what we charge and what the insurance plan will pay. Patients who consider our fees excessive can complain, or switch to another practice. We can accept the check, but decide that we’re not getting enough for our services and stop taking patients with that insurance. That’s what’s happened to a lot of Medicaid patients. We can stop taking insurance outright, with patients paying out of pocket and then submitting the bills to their insurance companies for reimbursement on their own time.

      Were the government to say that I have no choice but to accept the checks, keep seeing the patients, and charge nothing more for my services, then yes, I would find that state of affairs highly objectionable. If I were told I couldn’t quit, then I would consider that tantamount to slavery. However, I also find that outcome highly unlikely, and thinking that posits it does seem overwrought to me.

      How much money do I deserve for the stuff that I do? There’s a lot to that. How much do pediatricians deserve to make? Well, I’d certainly like to make the industry standard, with the assumption that the cost of being accessible to as many patients as possible is baked into the cake. Now, perhaps I am a particularly good doctor. Perhaps I have additional expertise, or am extraordinarily accessible to my patients. Perhaps I take pains to meet a high academic standard. If my patients agree that I am an especially good doctor, is it unethical to charge more than the industry standard [hypothetically — this is not a comment on what my actual practice really charges] if I am worth the premium? Is everyone entitled to see the very best, or simply to get competent care within a reasonable span of time?

      • Is there a point at which you’d be willing to say “you know what, I’d rather jerk taps at the local bar, the hours are better and people appreciate what you do for them rather than resent you for it”?

        There probably is (and exchange “jerking taps” for “flipping burgers” or “ringing up comic books” as may befit you personally), now that I think about it…

        Would you say that the changes to the medical profession over the last… how far back should I go? The 80’s? 30 years has moved you closer to wanting to throw beers? Have you stayed in the same place (maybe for different reasons balancing out)? Have you moved farther away from saying “heck with it”?

        • I haven’t been in practice long enough to really assess changes over generations of providers. I have worked in a variety of settings since graduating from medical school, and the one I’ve landed in is as good as I can realistically hope for.

          Are there conditions that would cause me to throw in the towel? Sure. If I got sued for something that felt frivolous or out of my control, particularly if it ended up consuming a lot of my energy and resources to fight it. If something profoundly negative were to alter how my current practice does business. If I magically get offered a career to sit in front of a camera offering my opinions for scads of money. But nothing that seems like a particularly plausible scenario just now.

          I plan to write a “how the culture of medical practice has changed” post soon, as a follow-up to my recent post about part-time practice.

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