As I’ve long suspected, “health care reform” has emboldened the Justice Department to take a more active role in enforcing government price controls against physicians. Today the Antitrust Division, joined by Idaho Attorney General Lawrence Wasden, forced a a group of Boise orthopedists to accept price controls for worker’s compensation and HMO contracts as part of a settlement accusing the doctors of “price fixing”:
According to the complaint, the conspiring orthopedists engaged in two antitrust conspiracies, which took place from 2006 to 2008. In the first conspiracy, through a series of meetings and other communications, the orthopedists agreed not to treat most patients covered by workers’ compensation insurance. They entered into a group boycott in order to force the Idaho Industrial Commission to increase the rates at which orthopedists were paid for treating injured workers. The Idaho Industrial Commission sets the fee schedule that determines the amount that orthopedists and other healthcare providers usually receive for treating patients covered by workers’ compensation insurance. The boycott resulted in a shortage of orthopedists willing to treat workers’ compensation patients, causing higher rates for orthopedic services.
In the second conspiracy, all of the defendants, except [one], and other conspiring orthopedists agreed to threaten to terminate their contracts with Blue Cross of Idaho. They jointly threatened to terminate their contracts to force Blue Cross of Idaho to offer better contract terms to orthopedists.
The proposed settlement prevents the Idaho Orthopaedic Society and the named orthopedists from agreeing with their competitors on fees and contract terms. The settlement also prohibits them from collectively denying medical care to patients, refusing to deal with any payer or threatening to terminate contracts with any payer.
This case is a watershed for two reasons: First, until now the Federal Trade Commission, not the Justice Department, has taken the lead in prosecuting physicians. Since 2000, the FTC has brought about three dozen cases against physicians (all but one of which settled without any trial). But the FTC only has civil and administrative jurisdiction; the Antitrust Division has civil and criminal jurisdiction. The Sherman Act makes no distinction between civil and criminal “price fixing,” so in a case like this, it’s entirely a matter of prosecutorial discretion whether to charge the doctors with a civil or criminal offense. Based on the descriptions in the Antitrust Division’s press release, there’s certainly no reason they couldn’t have prosecuted the doctors criminally and insisted upon prison sentences — and there’s little doubt such threats were made or implied to obtain the physicians’ agreement to the proposed “settlement.”
The second reason this is a landmark case is that the Justice Department has unambiguously stated that refusal to accept government price controls is a form of illegal “price fixing.” The FTC has hinted at this when it’s said physicians must accept Medicare-based reimbursement schedules from insurance companies. But the DOJ has gone the final step and said, “Government prices are market prices,” in the form of the Idaho Industrial Commission’s fee schedule. The IIC administers the state’s worker compensation system and is composed of three commissioners appointed by the governor. This isn’t a quasi-private or semi-private entity. It’s a purely government operation.
What’s more, the Antitrust Division has linked a refusal to accept government price controls with a refusal to accept a “private” insurance company’s contract offer. This lives little doubt that antitrust regulators consider insurance party contracts the equivalent of government price controls — and physicians and patients have no choice but to accept them.
Despite this, Antitrust Division chief Christine Varney, an Obama political appointee, insists she’s trying to protect “competition”:
The orthopedists who participated in these group boycotts denied medical care to Idaho workers and caused higher prices for orthopedic services. Today’s action seeks to prevent the recurrence of these illegal acts and protects Idaho consumers by promoting competition in the healthcare industry.”
The Idaho attorney general compounds the lie:
The free marketplace works best when there is fair competition. Anticompetitive activity harms the marketplace, businesses and consumers. Enforcement of the antitrust laws restores competition to the marketplace to the benefit of businesses and consumers and the marketplace as a whole.
But what “competition” do they refer to? The IIC fee schedule is set by government fiat. There’s no “competition” among orthopedists — or any other physicians for that matter. Everyone gets paid exactly the same “acceptable charges” based on the schedule. Even in the case of the Blue Cross contract, the physicians weren’t “competing” on price; they were simply told to accept the reimbursement levels proposed by the insurer.
And as much as the government would tout the “conspiracy” among physicians, as I said yesterday, we’re basically talking about people having conversations with one another. The truth is the antitrust regulators don’t need much to establish a Sherman Act “conspiracy.” Even if there’s no evidence of direct communication between physicians, if a large number of physicians in a given market individually reject a government price control scheme or insurance company contract, the Antitrust Division can simply “infer” the existence of a conspiracy.
This is another reason why the DOJ’s presence in a physician case is more disturbing than the normal FTC case. The DOJ has a number of “tools” the FTC does not, including the self-granted power to award amnesties from criminal prosecutions to the first “conspirator” to step forward and provide evidence against one’s competitors. A doctor that feared prosecution could seek amnesty — and provide the Justice Department a blank check to rummage through his files and private communications. And if that doesn’t work, the DOJ can always seek wiretaps of physicians’ phones and computers, a power awarded the DOJ during a 2006 renewal of the PATRIOT Act. The potential exposure of your physician’s confidential records — including your medical records — is limitless.
And while I usually caution against reading partisan political motives into an antitrust case — and I’d note the Idaho attorney general is a Republican — it’s hard to segregate today’s action from the larger political context of “Obamacare.” Christine Varney is an Obama political appointee, and if the Idaho case is an indication her Division plans to take a more hands-on approach to dealing with local physician groups, this policy will quickly degenerate into political demagoguery. It’s just too easy to label physicians “price fixers” and scapegoat them for the failure of government planning of the healthcare industry.
UPDATE: The DOJ has released the proposed order and other documents. It’s a naked censorship order that restrains the physicians from
(A) encouraging, facilitating, entering into, participating in, or attempting to engage in any actual or potential agreement or understanding with, between, or among competing physicians about:
- any fee, or other payer contract term or condition, with any payer or group of payers, including the acceptability or negotiation of any fee or other payer contract term with any payer or group of payers;
- the manner in which the defendant or any competing physician will negotiate with, contract with, or otherwise deal with any payer or group of payers, including participating in or terminating any payer contract; or
- any refusal to deal or threatened refusal to deal with any payer;
or
(B) communicating with any competing physician or facilitating the exchange of information between or among competing physicians about:
- the actual or possible view, intention, or position of any defendant or his or her medical practice group, or any competing physician concerning the negotiation or acceptability of any proposed or existing payer contract or contract term, including the negotiating or contracting status of the defendant, his or her medical group, or any competing physician with any payer or group of payers, or
- any proposed or existing term of any payer contract that affects:
- the amount of fees or payment, however determined, that the defendant, his or her medical practice group, or any competing physician charges, contracts for, or accepts from or considers charging, contracting for, or accepting from any payer or group of payers for providing physician services;
- the duration, amendment, or termination of any payer contract; or
- the manner of resolving disputes between any parties to any payer contract.
The order also illegally legislates through the courts by requiring the physicians to adhere to the 1996 Department of Justice and Federal Trade Commission Statements of Antitrust Enforcement Policy in Health Care, which is not law but merely the subjective opinions of unelected government antitrust lawyers. The order also requires the physicians to make “all books, ledgers, accounts, records, data, and documents,” available for government inspection at any time in the next ten years.
Since this is an DOJ case, it is subject to final approval by a federal judge in Idaho. There’s a mandatory 60-day public comment period, after which the judge will almost certainly rubber stamp the order as being “in the public interest.” Still, there’s at least an opportunity to express some serious dissent to what’s transpired here.
2ND UPDATE: It turns out the Idaho physicians hired the guy who used to run the Antitrust Division’s litigation department — and developed the government’s anti-physician antitrust rules — to represent them. No wonder they settled without a fight.
{ 95 comments }
It seems to me that these orthopedists are essentially acting as a union here, and one of the better ones at that in that they are only going “on strike” and aren’t attempting to prevent others from doing their jobs in the mean time. My understanding of the current US situation is that unions are allowed in modern times so where is the clear dividing line between being in a union and an illegal price fixing conspiracy? Is it just the fact that they haven’t officially registered as a union, or perhaps you just can’t belong to a union if you employ others in turn?
Also in making them unable to refuse to provide service to particular groups it seems to be getting very close to the socialist idea of having be illegal not to have a job, but hopefully I’m misinterpreting this part…
A little time in the camps will soon awaken the social(ist) conscience of these wayward docs.
snicker
It continues to amaze me that Federal and state governments, and their spokespeople, lecture us about “preserving” competition. There is anything but. I am an Orthopaedic Surgeon in Pennsylvania, and like Orthopaedic Surgeons nationwide, the Center for Medicare Services, which administers Medicare, tells me what they will pay me, and that’s that. I can’t negotiate the fee. My patients older than 65 are all insured by one provider (the government), and it is illegal for me to require or accept payment in addition to the Medicare fee. In fact, it is illegal for me to accept a cake that a Medicare patients makes for me and my staff as a gift of appreciation. Where is the competition here? It is a command marketplace. Because all the other insurers for people not covered by Medicare base their rates on Medicare rates, there is essentially no free market in that instance. In fact, the antitrust exclusion for health insurance means that in Western Pennsylvania, one insurer has 60% of the market, a second has 30%, and 4 other insurers split the remaining 10%. Why isn’t that anti-competitive?
So what happens when Orthopaedic Surgeons, and other physicians, stop practicing and pursue other careers, and no one, or less qualified individuals, replaces them? How does that affect “access to care” any differently than refusing to accept certain insurance plans?
“So what happens when Orthopaedic Surgeons, and other physicians, stop practicing and pursue other careers, and no one, or less qualified individuals, replaces them? How does that affect ‘access to care’ any differently than refusing to accept certain insurance plans?”
This astute observation, in my opinion, is at the heart of the health care debate. Most people that visit this site realize that when one claims to have a “right” to health care, that person is also saying that they have a “right” to another person’s labor. Unfortunately, many Americans are unable to understand this.
Attempting to limit physicians’ pay was by design. Rather than take over the health care industry all at once, the socialists decided to do it incrementally. Limiting pay to physicians will force some doctors to quit practicing medicine. As more and more doctors leave the field, all that remain will be those employed by government/non-profit health clinics. Before too long, socialized medicine is at full force.
Oh, how the yoke chafes!
Perhaps it would help to alleviate your distress to view your situation from a more positive perspective. You know, sort of a “count your blessings” thing.
First, you have the force of that same government acting on your behalf daily, as a karmic, yin-yang, counterbalance. I am referring to the myriad laws and rules regulating entry into your profession, thus serving to limit competition, thus increasing demand for the services you personally provide, thus enabling you to set your fees higher than you might otherwise.
Second, you always have the choice to OPT-OUT. Bear in mind that by not opting out you are positively opting in. That means the government is NOT forcing you to accept its fee schedule! Your choice is guided by the result of your costs vs. benefits calculation.
Third, in my opinion, it is the difficult choices we make that are the most satisfying. (The consequence of a sub-optimal result of a choice is a better choice in the future. Make choices early and often.)
Bless you for your service to your fellow man.
Regards,
Don
Oh Donald, thank you for pointing out the (almost) obvious that no one else will.
The AMA in partnership with state governments has been limiting entry in to medical schools as well as other medical training for decades. Lately they have been whining about the costs of medicine for their social programs, while continuing the practice of “limited entry” for doctors.
It seems the 10th amendment shoe is on the other foot now.
Either foot, government price fixing does not work.
Medicare, et al, is the largest single stifler of doctors in training. They pay for most of the residencies (don’t ask me how that got started) and have limited the number in spite of continued appeals to increase them.
The problem with the game as it is played now is it is like playing poker and your only options are to fold or go all in. You are so correct that the state is both our protector and tormentor. In an ideal world all parties should be able to hedge our bets.
I think there are legal ways for Docs to come together and negotiate better rates. In New Jersey many different pediatric practices were organized under the umbrella organization “Children’s Healthcare Assoc” I believe and were able to negotiate better rates while keeping their separate practice identities intact. It also happened her in New Jersey with the cardiologists who organized under the umbrella organization “Associated Cardiovascular Consultants”. The issues brought out in Idaho have been going on for years in Doctors getting together and negotiating. It needs to be structured through a legal entity and then the anti trust issues cannot be brought up. I would suggest that Dr. John Tedeschi the pediatrician who started “Children’s Healthcare Associates” be contacted to learn more. I hope he doesn’t mind that I posted his name here but he’s well known and respected in the New Jersey medical community.
Dr. Anthony,
You can certainly opt out of Medicare and then offer cash discounts to your patients. You are wrong to state that all other insurers base their rates on Medicare rates. Many of our contracts with commercial payers are based on a percentage of billed charges. One could probably extrapolate what that reimbursement equals in terms of Medicare, but the rates are not based on Medicare. I would challenge your anectdotal remark that one insurer has 60% of the market and a second has 30% as much as I would challenge the anectdotal statement that most orthopaedic surgeons are money-grubbing robots who care more about their new boat than they do their patients.
Let’s assume CMS raised the MPFS 100%. Who is going to come up with that extra cash to line your pockets? Increased taxes or all our our parents living on fixed income? If $300K (low range for conservative argument) is not enough for you then you can leave the profession, go sell real estate, make your millions, and leave those physicians who really are in the profession to help people to treat patients. I’m certainly not opposed to an individual making a dollar, that’s why I chose not to be a physician– I can make more money is sales. However, people can do without my products and services and still live comfortable lives. Healthcare is very inelastic and so the free market governing rules are not so identical in the healthcare industry as they are in the widget industry.
cheers,
jj
@jason, I read your posts below. You certainly are an Angry Elf. BOTTOM LINE UP FRONT: The cost of healthcare isn’t being driven by physician salary but all the other factors I list below.I infer from your other comments, that you are in favor of a socialized system. Most doctors aren’t. If you really want socialism, then go to Canada for your care. You can’t allow uncapped tort, pharmacy, medical school tuition and not expect that doctors want payment in the same manner.Your comments indicate that you don’t like the fact that physicians demand good pay for their services. In that case, you can see a physician who is happy making government pay. Hope he is competent.As for me, I want the doctor who is demanding good pay. His wait will be shorter and he will have to be competent or his patients will leave.
P.S. look at Mayo Clinic of Arizona for an example. They are cutting edge and don’t accept medicare/medicaid.
Mr. Opinion,
I would appreciate if you left my pointy ears out of this discussion. I am very sensitive about that. How we got from US physicians colluding together in Idaho to a discussion on socialized medicine I don’t know. But in order to have an intelligent dialogue, I need to know your understanding of a socialized system. Canada has a universal health insurance system. Most physicians are NOT employed by the state; hospital based physicians are rarely hospital employees. Public AND private entities provide healthcare services. So let me know how this is socialized medicine and then once were on the same page, we’ll talk. I’m not advocating the Canadian healthcare system, just pointing out your ignorance.
I never said anything about physician salary being the main culprit to high costs of healthcare. I’m all for tort reform. My comments certainly do not indicate that I think physicians cannot demand good pay for their services. It’s just a little difficult to hear someone complaining about their salary that is 20 times the Federal Poverty level. And don’t even start with debt load because you will lose that argument every time. Even extreme examples have medical school debt paid off in 7 – 10 years.
http://ezinearticles.com/?5-Strategies-For-the-Physician-to-Pay-Off-Their-Medical-School-Debt-in-12-Months&id=3494940
“As for me, I want the doctor who is demanding good pay. His wait will be shorter and he will have to be competent or his patients will leave.” — First of all you wouldn’t be able to afford that physician, so while I appreciate that you would want him, your wallet will be telling you to see someone who has fulfilled their training and is competent in their profession. His wait will be shorter because nobody can afford his prices. Conversely, if his prices are affordable and his competence is second to none, his wait will be enormous.
Like they always say…. “Good, fast, and cheap — pick any two.”
“P.S. look at Mayo Clinic of Arizona for an example. They are cutting edge and don’t accept medicare/medicaid.” — O.k., now you are making yourself look foolish. You are doing the same thing as the author of this article. Misconstruing and misinterpreting the facts to blast out one’s agenda. You are taking one obscure case and trying to make it seem relevant.
http://healthpolicyblog.mayoclinic.org/2010/01/05/medicare-and-mayo-clinic-in-arizona/
So there is the link to the story (from the Mayo Clinic Web site no less)… it is a five-physician Mayo Clinic family practice in Glendale, Arizona…. part of a limited trial. And it doesn’t mention anything about Medicaid.
Don’t want to take away anything from the folks there in Arizona, but they are not the same Mayo Clinic as the one in up in Rochester, from which the brand was build.
Yeah, good example.
Again, I’m not trying to state that Medicare payment are high or that there are a number of issues with our healthcare system that if fixed can improve inefficiencies; just showing your ignorance.
try again,
jj
If you had any idea the amount of intelligence, motivation, and sacrifice it took to become a doctor, much less a orthopedic doctor, you would not see things in such a way. The reason doctors deserve 20 times higher than the national poverty rate is because of the demands of the profession. How many 80 hour work weeks (which was just recently established as the cap ) have you worked? When’s the last time somebody died in front of you because you couldn’t make split decision that required you to recall information that you learned somewhere along the line of your 11 years of training?
What we’re talking about is the government forcing someone to work. You really can’t go into another profession when you have invested 11years and hundreds of thousands of dollars.
And also let me just put this out here. Most people are not mentally capable of doing this work. Just as not everyone is physically gifted enough to play in the NFL or NBA ( where we don’t care that tickets are hundreds of dollars and the players make 20 million plus) not everyone is mentally gifted enough to practice medicine. When it’s your chest spread open on the table, do you want the best in the world? Or do you want a federal employee who hates their job?
“who is John Gault?”
The Center for Medicare Services is harmful to our society and should be rendered ineffective by whatever non-violent means are possible. That is the economic thing to do, to find the best means to attain the ends!
How do you go about commenting during the 60-day period? That is, do you file something with the court or do you follow another procedure?
Comments are filed with the Antitrust Division, not the court. By law, the DOJ must file all comments received with the court together with an official reply. The court is then supposed to take the comments and reply into account when determining whether entry of the proposed order is “in the public interest.”
Comments should be sent to Joshua H. Soven, Chief, Litigation I Section, Antitrust Division, U. S. Department of Justice, 450 Fifth St. N.W., Suite 4100, Washington, D.C. 20530. Soven’s fax number is 202-307-5802.
The 60-day clock doesn’t start until the proposed order is published in the Federal Register, which might take up to two weeks.
Thank you. Should make for a fun summer project.
It seems ironic that a half-black President with delusions of grandeur, that he is like Abe Lincoln, should now seek to enslave doctors. His apparent goal is “to increase access to care”, while the reality is that he seeks to curtail care for the elderly as advocated by Daschel. Neither of them will accept the quality of care that they mandate for the elderly or nation.
What is the difference in benefits for the slave when he/she is enslaved by:
a) Private citizens?
b) Private industry?
c) The government?
Is is OK for the government to practice slavery?
The liberals/progressives are leading us right back into slavery.
Is that progress?
Hubert,
I have many of my docs comment (especially when treating folks from other countries) that if you don’t like America, don’t let the door hit your ass on the way out. “Love it or leave it!”
Well, if physicians don’t like the their profession, then leave it. It sounds like they are all about the money anyways, so go do something that pays you more.
I don’t know if that same option was afforded to slaves. I don’t think they could leave their current state and start selling real estate, do financial planning, be a medical consultant, be a PE, hell, for that matter, go flip burgers at McDonalds. I would imagine a slave in the 1800′s would have done anything for the opportunity to flip burgers and get paid for it. For slaves the only alternative was a bullet in the head. Yeah, I can see how you view the two situations as the same. What a joke.
Jason,
You have shown your TRUE COLORS with your posts. Obviously you do not believe in competition or a free market society. Medicine is NOT a RIGHT of the people! It is a commodity sold and practiced by physicians who have taken on the debt to educate themselves. Physician salaries are only a very small part of the overall cost of medicine in this country.
I entered medicine after a successful career in engineering and find that it is very rewarding to care for patients who appreciated good care. I stopped seeing Medicaid patients several years ago, mainly because they were non-compliant with care and the first to file a lawsuit for having a bad illness.
You cannot force physicians to see patients for less than it costs to run their practice.
Obviously, you would see things differently if the government came into your business and mandated that the price of your widget is now 60% less than what you charged yesterday, and you have no recourse. This would especially hurt if you had just retooled your facility to make these widgets and now owed a $250k. This is the equivalent loan/debt that many students take on to go through medical school.
Perhaps you need to start paying cash for your physician to learn the true value of healthcare in this county. I agree with your comments, if you don’t like this country, LEAVE. If you want to have socialized medicine, don’t let the door hit your bottom while you MOVE to Canada. You can join the many dissatisfied Canadians who travel to the US for health care.
Anonymous Doc,
The leaps you are making to come to the conclusions about my philosophies or beliefs are amazing. I hope you are not diagnosing your patients with that same approach. No wonder you have folk suing you. BTW – the reason you stopped taking Medicaid is because it pays so poorly. Don’t be so ridiculous.
I absolutely believe in competition, but I don’t believe in parties colluding together to limit a supply of a commodoty unless the consumer ponies up a ridiculous price. If an individual doc or physician group wants to opt out, feel free, but when parties collude together, they are not letting market forces act naturally.
I have never even hinted that physician salary is the reason for high health care costs in this country. There are so many reasons for that and physicians’ salaries are far from the top. However, I do believe many will debate whether physicians’ salaries over a lifetime are commensurate with their education and training. By comparison, a physician’s debt load is meager compared to other professions.
“You cannot force physicians to see patients for less than it costs to run their practice.” —
Wow. Where do I begin with this comment…. 1) Nobody is forcing you or any physician to treat any patient. In fact, you should know you can dismiss any patient from your practice at any time if the case warrants it. 2) WC pays better than many commercial payers so to imply that seeing WC patients puts your practice upside down is ridiculous — especially an orthopaedic practice where musculoskeletal surgies are 200% of Medicare and Radiology is 190% of Medicare. 3) Maybe if you didn’t cut yourself a check for $250k a year, your practice would be more profitable and you could use some of those retained earnings to grow your practice. 4) Since you negotiate your own contracts you know that commercial payers make up for government payers’ fees. My premium wouldn’t be so high if you didn’t demand so much from my insurance carrier.
“Obviously, you would see things differently if the government came into your business and mandated that the price of your widget is now 60% less than what you charged yesterday, and you have no recourse.” — You are convincing me more and more that you are a physician and not a businessman. 1) The government cannot mandate that I charge 60% less for my widgets — just like they are not telling each of these entities in Idaho they have to charge less. 2) If the government only wants to pay me 40% of my price, guess what…. I’m not selling. Especially if I’m losing money on the transaction. However, I may entertain their price if there is some margin — albeit not the 300% markup I charge other customers — and I’m not good enough to drum up other business from other consumers. That’s the funny thing about healthcare — EVERYBODY is a customer. Please tell me one other industry like that where the demand is infinite. And please don’t say the food and farming industry because we all know the thousands of folks who are allergic to or don’t eat anything from peanuts to gluten to anything but rainwater. Furthermore, if I can’t make the margins I want at this business, then maybe I have to find something else to do like engineering. I hear there is tons of money in engineering and I’m all about the money.
‘This would especially hurt if you had just retooled your facility to make these widgets and now owed a $250k.” — Not very smart to retool your facility without a intelligent proforma or business plan. Even worse one based off of faulty assumptions. People make investiments much greater than $250k each year and then go out of business. And their customer base wasn’t infinite. Furthermore, even at a 60% reduction in price, you still make a profit in your business. Maybe you can’t buy that vacation home in South Florida to go along with your home in Tahoe, but hey, at least you are doing what you love and helping others.
“if you don’t like this country, LEAVE. If you want to have socialized medicine, don’t let the door hit your bottom while you MOVE to Canada. You can join the many dissatisfied Canadians who travel to the US for health care.” — 1) First of all, many, many, many (did I say many?) more Canadians are satisfied with their healthcare system than Americans with theirs (I believe the statistics say 70% approve of Canadian healthcare and 20-something approve of the US healthcare system — but hey, that’s just because Canadians are stupid and don’t know good healthcare, right?). That being said, Canada is certainly having to come to terms with their system as much as America is with its. I love this country. Are there some things I don’t agree with or would like to see changed? Of course, but all in all, I’m grateful to be living here. I’ll take the inordinate amount of good with the bad. I don’t want to have socialized medicine in this country. If we ever got to that point (which A, we aren’t even close to socialized medicine and B, never will) then I would have to re-evaluate.
cheers,
jj
This is beyond unbelievable. Vote all of these MF’s out in November.
Sorry, but I have to agree with the government’s case here. It’s not a question of individuals taking these decisions separately, on their own initiative, but rather doing it as a group, to coerce higher rates since there is no other competition to their essential services.
Take the following more extreme example: All emergency room doctors in the state get together, and refuse to work unless they are paid 10 times their current salary. Should that be allowed? Should they be allowed to hold people’s lives hostage to force huge increases in salary? ie “If you don’t pay me $1 million for bandaging you, I’ll let you die on the street”.
Example 2: Your house is on fire, and the fire department refuses to put out the fire unless you pay them $50,000. There, is, obviously, no competition to them. Is that OK too, in the name of capitalism?
If not, where do you draw the line?
Collusion between ALL doctors to refuse work should not be allowed. This is NOT the same as a union at an automaker. If your new car is more expensive due to high worker wages, you suck it up or get a used car. If your life is in danger, you have an expectation to treatment at a reasonable price. Whether it’s fire or police protection, or doctors. Those essential groups must NOT be allowed to form unions, and prices have to be kept at a reasonable level through price controls. This is NOT socialism, it’s realism.
Randy,
I am guessing that you have no experience as a physician treating Worker’s Comp patients.
The “oversight” and paperwork hassle demanded by the Work Comp system of the doctors who agree to see those patients is egregious from the get go. It is not at all infrequent for a physician to come up with a plan of care for an injured worker only to later have that plan usurped by some other doc or bureaucrat within the WC system. It becomes an absolute paperwork and telephone calling nightmare to deal with these cases such that where I am at least, the majority of docs won’t take these cases. It isn’t a matter of money solely, it is more a matter of “how much are you willing to pay me to put up with your administrative/control B.S.?” I am sure these surgeons would be happy to work for the reimbursements WC offers if WC would simply stay out of the surgeons’ way and let them do their jobs without argument or question. WC doesn’t do that however. They want control. They don’t view it as a matter of patient’s health. They view it as money being taken from their pot of gold. I personally will be happy to work for WC rates if they simply shut up and stay out of my way and plan of care until I am done with the patient.
I frequently will get continuing medical education solicitations in my mailbox for all manner of educational offerings. Numerous times I have gotten “Navigating the Work Comp Sytem” seminar offerings. When you look at the speaker profiles and lecture topics, they aren’t related to patient treatment/industrial medicine. Instead, near every one of them is a lawyer or business type speaking about “limiting payouts”, “managing costs”, and “denying claims”! The simple fact is that the WC system is set up to pay out as little as possible while still “in name only” allowing the provision of just enough care to say they paid for the patient’s treatment.
As a doc who used to work with primarily WC patient’s (and still do to a small degree, begrudgingly) I can say without hesitation that every doc out there out to boycott WC specifically and insurer’s in general not over payment, but over control. No one should have ANY say in the care that I provide my patients other than me/the treating physician. I will humbly as I can say that the vast majority of my patients LOVE the care I provide them. I get their accolades and praise near daily. A few, looking to pull the wool over my eyes about this, that, or the other thing, don’t like me when I call them on it and I tell them that I’m not the doc for them might say otherwise, but then they are more than welcome to go elsewhere and get their high dose opioids or disability forms from an ethically compromised provider.
For example, I recently treated a patient with low back injury after a lifting accident. She had been to numerous other providers and not gotten any treatment that helped her. Then, I suspected she had torn a very specific ligament (ligaments heal very poorly, btw). So, I did an anesthetic block of the ligament in question. She immediately had 100% relief of her pain and this lasted 3 days. So, I ordered prolotherapy to restore the ligament’s integrity. WC denied this. The woman still has pain and is off work. prolo has been around since 1940. Yet, WC in their genius declined to pay for this “experimental” treatment. There is no other treatment for an overly stretched/sprained ligament that doesn’t involve surgery and believe me, no surgeon is going to touch this patient. So, after much telephone calling and endless documentation, WC decided to send her to another doc. For all this nonsense, after hours dictating, multiple patient visits, my own frustration, and my hard-earned expertise, the patient still has her severely limiting back pain and I got paid about $200 in total. The prolo would have cost probably about $1000 in total. Instead, I am positive that the patient is still hoping for a solution, and WC is still fumbling around with this case. She will probably never find pain relief without the prolotherapy but I am guessing that somewhere along the way she will become addicted to opioids and get a permanent disability rating at the taxpayer’s expense. Why? Because, WC can’t sit down, shut up, and let doctors do the doctoring. Instead they fight for control as though they are “serving” the patient. Trust me, they serve only themselves.
Dr. Brett,
Please tell me you are not so naive as to believe all physicians are so altruistic that they treat their patients without any influence of kickbacks and incentives. Talk about the wool over one’s eyes. Why do you think attorney’s select “certain” physicians to perform IME’s or companies include (or exclude) certain physicians from their work comp panel listed in the break room. The ordering of MRI is the quintessential case study of physician abuse. Based upon your comments, I suppose you are ademately opposed to EBM, because that would take away your autonomy to treat your patient they way your learned in your residency in 1980′s. Just like you point out one example of WC bureaucracy failing a patient, we could point out scores of examples of physicians abusing the system — for their personal gain, not for the good of the patient. I am not naive enough to believe that WC, insurers, and Medicare are trying to keep down costs. They will say at the benefit of their members, but I’m inclined to think a bonus or two for an executive hang in the balance of annual medical expense spend. However, if we suscribe to the pareto principle, the large majority of their medical policies are sound and defensible.
I would be curious to see how many patients LOVE their physicians if they had to pay the full brunt of the services instead by a third party payer. We have folks complaining about a $40.00 co-pay!. I would be interested to know the CPT codes you billed out when you did the injection. Medicare pays about $100.00 for the office visit (99203) and about $250 for the injection (64479). As you know, WC pays between 150% to 200% of Medicare (depending on where you practice), so that visit (reimburse by Medicare for $350) should have paid around $600.00 for the hour (grossely overestimated) that you spend with the patient. These $ values are based off of unknown assumptions (don’t know what CPT codes you used, don’t know where you practice, don’t know your state’s WC fee schedule), but they are based on national numbers. I wonder if your coder coded the visit incorrectly or if denied for lack of notation. Just curious.
cheers,
jj
“All emergency room doctors in the state get together, and refuse to work unless they are paid 10 times their current salary. Should that be allowed?” — Of course.
“Your house is on fire, and the fire department refuses to put out the fire unless you pay them $50,000. There, is, obviously, no competition to them.” — Why is that obvious?
“Collusion between ALL doctors to refuse work should not be allowed.” — They should instead be slaves of the State?
It’s about time the gov. stepped in over the cost of healthcare in this nation, As a persion who has to pay these cost, Doctors have been raping the public for years getting rich. The average persion in this country right now is having a hard enough time as it is keeping a job, getting a job ect. One of the reasions jobs are going away is the cost of healthcare among others, you know it’s bad when you have people in Texas that go across the boarder for there healthcare, It’s not really safe but it’s all they can afford. I don’t charge $5,000.00 for 45 min. work, or charge someone $125.00 just to visit me in an office for 30 min. Now the gov. just needs to go after the oil companies the same way.
Hmmm. So, you think that $125 for a 30 minute visit is “raping the public?” Did you think that the doctor was pocketing all of that or something? Usually, overhead for a physician practice is 50% to 60%–they have to pay their employees; there are costs in billing for the visit, there are costs in maintaining the medical record, and there are a lot of hidden costs caused by increasing government regulations. My CPA charges $190/hour. My attorney charges $275/hour. Heck, my mechanic charges $80/hour. Tell me again how $125/30 min is “raping the public???”
The Judge overseeing the Lehman Brothers bankruptcy case has allowed the lawyers dismembering that carcass to charge 2000 (yes, two thousand) dollars an hour and awards all expenses, including limo’s, on top of that. And this guy thinks physicians are raping the system?
A surgeon can perform a laminectomy in an hour (or less) and Medicare reimbursed $2,500. So, if comercial payers are reimbursing 150% to 200% of Medicare, that’s around $5,000 an hour. Puts those lawyers (who we all know are a parasite to society) to shame.
cheers, jj
I had to read this again. You mean to tell me that when a doctor does not agree to accept artificially low reimbursements, as set by the government, he is by default, price fixing? With the threat of prosecution? What kind of BS logic is that? The last I checked this was the United States. What happened to free market principles and the laws of supply and demend? Did the government pay for their educations? Did the government assume the costs and risks of starting a medical practice? And the insurance companies are exempt anti-trust laws? You have got to be kidding me. Did these guys do this with a straight face? Where did these Bozo’s from the FTC and DOJ come from? You mean to tell me that these people are the best we can find for these positions?
Amen Christopher RR. The thing that bothers me most of all: the average person is completely clueless as to this and many other governmental outrages.
We are truly down the rabbit hole.
Virtually all of these comments fail to note that our healthcare system is in crisis, and that the status quo is economically unsustainable. Simply put, something has to be done to contain the sky-rocketing cost of health care. Notwithstanding “Intransitions” reference to the cost of an office visit, study after study has shown that medical bills have increased well beyond the rate of inflation for quite some time.
The reference to these physicians as a de facto “union” is interesting. If one checks the law in this area, however, it is not only obvious that they do not qualify for protection as a union (e.g., what “management” would they all be employees of, for bargaining purposes?), but, even if they did, they would be subject to prohibitions against striking, as apply to many unions in public safety, national defense, etc… Accordingly, as Reagan did to the air traffic controllers, they could all get fired!
Finally, the references to these doctors as “slaves” is both comical and tragic (from the historical perspective). I have some friends who are such “slaves,” and I must say, their slave quarters, and slave-Mercedes, etc., have improved greatly since the pre-Civil War time frame!
“study after study has shown that medical bills have increased well beyond the rate of inflation for quite some time.”
Um, so? If costs increasing beyond the rate of inflation are obviously supposed to be
problematic, the alleged obviousness escapes me.
Medical costs are increasing beyond the rate of inflation because of increased prescription drug prices, increased utilization of the health care system by patients, and use of newer expensive technologies (for example, doing an MRI instead of a CT scan).
The amount that physicians receive from the government (or private insurance companies) has DECREASED over time. Ask any surgeon — an ophthalmologist today, for example receives a much lower payment for cataract surgery than he did in the 1990′s. The same is true of most medical procedures.
Effective January 1st of this year Medicare will no longer pay for consultations by subspecialists like me. They will only pay for a “new patient” office visit — which pays about 10-15% less.
When you take inflation into account most doctors are making SUBSTANTIALLY less per hour today than they did 10-15 years ago. When overhead is considered my plumber makes more per hour than I do.
Dr. Jack,
The amount that physicians receive from the government has decreased for some CPT codes and have increased for others. If your reimbursement from private insurance is decreasing you are doing a poor job of negotiating rates. That’s your fault, not the government’s fault. With new technology, cataract surgery takes a fraction of the time that it once did. You are crazy to say most medical procedures are reimbursed less than they were in the 1990′s. I am amazed at all the surgeons on this board that are supposed to be experts when it comes to details, yet they are so far off on the details they are purporting on this thread. Do they not think anyone will take two minutes to research their claims to see how far off they are?
The reason why Medicare got rid of consultations was because it was being grossly abused by subspecialists (obviously not by you — but by many of your collegues). You did fail to mention how E&M reimbursement was increased by Medicare in 2010, and in a normal orthopaedic practice (including Physical Therapy) 2010 Medicare pays 3% higher than 2009 Medicare.
“When you take inflation into account most doctors are making SUBSTANTIALLY less per hour today than they did 10-15 years ago. When overhead is considered my plumber makes more per hour than I do.”
1) WRONG
2) Right size your overhead!!!
3) Physicians, especially specialists spend less than 10 minutes with their patients where as 15 years ago a patient at least got 20 – 30 minutes with their doc.
4) PAs are doing much of the office work, but the Physicians get paid for it and then pay their PA a salary.
5) I bet your plumber isn’t driving a Mercedes
6) And if so, get a new plumber. He is way over billing you.
7) If you don’t want to pay to unclog your toilet because the plumber charges too much, you just live with a clogged toilet. If you don’t want to get those cataracts fixed because your doctor wants more money that you can’t afford, you go blind. Not as much choice in the matter as there is about a clogged toilet, is there?
cheers,
jj
While it is probably not the case in this instance, many doctors, especially ER docs, are contract employees of a company hired to provide physicians to that ER.
I am a Texas orthopedic surgeon and think this decision and the involvement of the attorney general of the USA is an awful harbinger of things to come. In my opinion, the idea of limiting competion and limiting access to orthopedic surgeons in Boise is trite and not true. From the American Academy of Orthopedic surgeons website listing, there are 45 Board certified orthopedic surgeons in Boise, so 5 surgeons in one group making a decision to limit patients of workers comp or from a private insurance would not limit competition or access to orthopedic surgeons. The other 40 orthopedists would take care of these patients. This was a blatent power grab of the Feds to send a message that governmental prices are the new standard, and do not try to fight it, for the next “offenders” may get prison time.
Finally, a well-thought out, competent response by a practicing provider!!! Thank you Dr. Fogel for restoring my faith in intelligent, articulate orthopedic surgeons. Your points are very well taken. One needs to look at this particular case details and understand the circumstances before automatically assuming unfounded facts and permutations throughout the whole medical community. For example, this type of “discussion” or “collusion” or “co-opitition” or whatever you want to call what the ortho docs were doing in Idaho would never be able to happen in a large metro area because of the accessibility. That doesn’t mean that this cannot set a precedent in other similar demographic areas, or in other areas of healthcare. And that is reason for another discussion.
cheers,
jj
Let me clear a few facts before we begin to break down this article:
1) The rising cost of health care is not the result of physician reimbursement. Out of every health care dollar that is spent only 21% goes to the physician. This 21 % is then spent to cover expenses, administration costs, salaries, benefits, malpractice. When all of that is spent the doctor may be lucky if he takes 5% of the health care dollar.
2) The amount that physicians have been reimbursed over the past decade have not kept up with inflation. There is a formula used by CMS to calculate physician reimbursement for medicare/Tricare payments. Currently there is suppose to be a 21% cut that goes into effect today unless congress intervenes (as it has done several times) to prevent it. This 21% cut is to be followed by another 5% cut next year. In the past 7 years there has been a total of 1% increase. When you figure that inflation is about 3% average per year you can see that in real dollars doctors are making 20% less then 5-6 years ago.
3) Nearly 100% of private insurers base their reimbursements on a percent of Medicare fee schedule. If there is a cut in the Medicare fee schedule you can expect that private insurers will follow suit.
4) Health care is not a “right” it is not guaranteed int he Constitution. Yes it is nice to be able to treat everyone and have health care for all in an altruistic fashion. However this belief of health care as a right implies that the service of doctors is a right of consumers to have equates to slavery (not in the sense of African Americans before emancipation-but the rights of one person to take the labor of another is slavery).
5) Never before has the DOJ been involved in a case of antitrust when it comes to physicians and contract negotiations. This adds a new element to an already difficult problem. Making physicians out to be the “bad guy” because they want to be paid fairly for their services is in itself a force for the worse. Second By allowing insurers to use a fixed government reimbursement schedule to set a price a form of price fixing?
Now about this article:
I feel that this is just another step in the administrations attempt to complete take over our health care system. In Mass. they are contemplating a law saying that in order to be licensed in Mass you must take all government insurances. With the DOJ involved they are taking civil matters and turning them into criminal. Are physicians who refuse to see medicaid patients now going to be prosecuted because they are violating the law? This is a bad precedent that will have nothing but ill effects on this country.
JABMD,
Your facts are inaccurate and I get very frustrated that people think that if you have a few letters behind your name or if you yell the loudest, then somehow what you say is true.
1) If a physician’s overhead is over 75% that is insane. I have never seen any orthopedic surgeontaking home less than 30% of gross revenues. And I’m not talking about those employed by hospitals with NO overhead.
2) All you have to do is go to the Bureau of Labor and compare MCPI to regular CPI.
3) Wrong, wrong wrong. About 80% of our contracts are based on a specific year of Medicare and NONE of them are based on current year of Medicare; their locked into a specific year and then annual escaltors.
4) I agree with you that healthcare is not a right, but you know as well as anyone that market forces are not the same in healthcare as any other industry. In another industry, if you can’t afford it, you go without the widget. In healthcare, you cannot go without in many cases and/or you go without until it gets exponentially worse and then the burdon of treatment on society is much greater than incremental treatment along the way. BTW- to equate physicians with slaves is not only ridiculous, it is an insult to African American history.
5) I would not object to sit down and have a dialogue on “fair” compensation for a physician. As an aside — I thought physicians entered the profession because they wanted to help people, but it’s all about the money. If you want to make mad money there are far more lucrative business out there.
cheers,
jj
JJ,
You really don’t know what you are talking about. JABMD made some good points and you have decided that all are incorrect. I am a solo practice physician who negotiates all of my own contracts, and will be the first to tell you that you are WRONG about your assumptions. Get out of this discussion until you learn about how a real medical office works.
CHEERS,
SS
Hey anonymous doc,
Please tell me where I am wrong in my statements. I can appreciate you are a solo practicioner, but please don’t assume that all healhcare economics are the same for everyone else as they are for you. You, as well as any physician should know the pros and cons of being a solo practioner. So just to be clear:
1) Your overhead is 75% or higher?
2) You believe Congress will allow a 21% cut to Medicare? Please tell you you are up to date with the recent goings-on in Washington. For a tyical orthopaedic practice (to include ancillary) 2010 Medicare is 3% higher than 2009. Latest fro AAOE states that more than likely there will be a 2.2% increase in reimbursement levels for June-December 2010, and an additional 1% increase for 2011.
3) You actually believe that 100% of 2003 Medicare is 20% lower than 2010 Medicare? (Especially for E&Ms and PT codes? — the only decrease close to this level would be in Imaging and some Nervous System Surgeries)
4) Nearly every single one of your contracts is based off of current year Medicare? Even Beechstreet, Great West, MCI…?
5) You are being forced to treat even one patient?
Please tell me with which of these points by JABMD you agree and on which points I have misstated.
Some physicians are so egotistical, it’s sick. If a patient or nurse or administrator or MA or anyone even questions or points our the error in their way, you get all pretentious and self-righteous like you know everything about everything. Get over yourself. You are just perpetuating that stereotype.
I hope you treat your patients with more clinical competence than what business competence you are showing here on this post.
Before doctors are made to accept such conditions there should be similar restrictions on lawyers.
The comments about slavery are on target or soon to be. What is the end goal for the government? It is to control doctors: what they do, what they prescribe, what they get paid and just about everything else via control of the purse-strings and regulation, but to not get exposed to medical liability by not making physicians out-right government employees.
The government is determined to create a one payer system or multiple payers who are themselves anti trust exempt and ERISA protected collude to control prices/ payments while physicians are not given the same privilege. Since the physicians are not part of a single group with a single tax ID number, they cannot “collude” to fix prices. But they would find a way to apply to law unequally and tell doctors that civil rights and equal protection do not apply to them. Sound familiar? Water boarding is NOT torture. Orwellian. Randian.
Political ideology means nothing because both parties want the same. They want to humble doctors and put them in a similar category as other intelligent professionals such as engineers: paid better than most but not independent and personally liable for millions of dollars of medical liability exposure due to some high school educated government agent’s medical decisions. I think Benjamin Franklin and the rest of the Founding Fathers are puking in their graves to see that this is where their country has ended up.
Soon the government and insurors will be paying the hospitals a flat rate for surgeries, letting the latter decide what to pay your surgeon and anesthesiologist. The crazy part is that physician payments only amount to 10% of Medicare costs. Don’t be surprised to see more stockbrokers with MD after their names.
I have a crazy idea and I’m not sure if it is legal. What if all doctors (may be even 30% will be sufficient) will stop to bill insurance (all of them including Medicare and Medicaid) and demand payment at the time of service (according to fee schedule)? The patient receives an itemized bill and receipt and let his insurance reimburses him! Can you imagine reduction in overhead and improvement in cash flow? Insurance probably will throw you off the panel and then it will be only cash basis practice. by the way, what a ridiculous rules to have to fill multiple pages of applications with info readily availabe for anyone? And why insurance may not accept a physician with valid license? How many more bureacracy we can tolerate? I think that 6 month will be enough to outrage public and push for tort reform and other sensible changes.
The DOJ needs to be careful about pushing docs too far, though, because the perfectly legal response from doctors might be that they stop accepting Medicare and other insurances altogether. The hypocrisy of trying to force price controls on providers without controls on cost and the profit made by insurance companies is ludicrous. It is a further argument for a national health system that covers the costs of medical education, and covers the overhead costs of physicians, that has true tort reform, and that offers a realistic and comfortable salary to those physicians who want that or a fee-for-service opportunity for those physicians who are workaholics. I cannot resent my cardiologist friend who is making a large income and who is in the hospital day and night, because I know that when I have my heart attack at three in the morning he will be right there at my bedside!
And I must agree with the writer who commented that if we are going to get a back-door approach to health care as a right then let’s also agree that legal representation is a right and that all attorneys need to work for the same reduced fee.
Hmmm why would an intelligent person decide to spend 8 plus years of college costing a couple of hundreds of thousands of dollars, years of grueling internship and residency, then long hours often on call 24/7, deal with life and death with the possibility of getting their pants sued off for this kind of aggravation? I predict there will be a big doctor shortage in my future, sad to say, in the years that I will need one the most
It’s 10pm where I am. I got to work at 7am and haven’t gone home. I do this many days each week. I get 4 days off each month. I often work more than 80 hours a week. I take additional night call 2-3 nights a week; on those nights I get a phone call every 15 to 20 minutes and its back to work at 7am the next morning—I sleep in another room at home on those nights so the calls don’t wake my spouse. That time spent desperate for more sleep is not reimbursed even one cent. I studied hard in high school and put off fun many times for a chance to be a doctor someday. I went to college for four years — and got top grades through hard work. Then I went to school for another 5 years as a graduate student in molecular biology. After that I went to medical school for 4 years. Then I trained in residency. Done at 34 yrs of age. My close friend from childhood completed his schooling at 18. He works as unskilled labor on an assembly line and makes about $45,000 a year with 40 hours of work a week. He can sleep 16 hours a night if he likes and has every weekend and holiday off. No one will ever sue him if he makes a mistake at work. When work is done, the day is done. No stress to take home. I myself have $140,000 of debt from school. He has been making money for 16 years while I accumulated that debt. He can see his family every night and is never too tired. Hell, he exercises for fun he’s got so much extra time.
I love taking care of people. I love being a doctor. But isn’t clear that this is a sacrifice? Who wants to trade with me? Someone wrote that doctors have been “raping the public”. Really? Is that what I was doing in the hospital tonight? If anyone wants to trade, they’ll need to be very smart, good with people, have good financial sense, and, if they want my job, able to go with very little sleep or contact with their spouse and kids. Shouldn’t be too hard to find this sort of people, right? Sure. Just place an ad in the paper.
Dr. Medicine,
From my perspective, you are making you and others who have chosen this profession look very foolish. From the way you portray things, sounds like your friend made a better career choice than you, not because he makes more money, but because he’s happy with what he does and the compensation / time that he has. Sounds like you are not. I don’t want to trade with you because I have different values than you. I’d rather make more money and have more time.
All that being said, let’s look at your comments:
“on those nights I get a phone call every 15 to 20 minutes” — We are trying to have an intelligent discussion based on facts here. There is no room for falsities and exaggerations.
“I studied hard in high school and put off fun many times” — High school is not hard; even with 6 AP classes and 3 college courses (spread out between my Junior and Senior year) I had plenty of time for extracurricular activities (lettered in 5 sports) and “many fun time with my friends. Give me a break.
“Then I went to school for another 5 years as a graduate student in molecular biology” — Not sure why that was necessary, especially if you are wanting to catch up to your friend as an income earner. I would suppose though, that this extra schooling hasn’t hurt you nor your compensation level currently.
“My close friend from childhood completed his schooling at 18. He works as unskilled labor on an assembly line and makes about $45,000 a year with 40 hours of work.” — Where do I begin… Let’s assume your friend works 80 hrs a week like you and therefore earns $90k a year. Throw in a couple of weekends and a Holiday or two for $100k a year. You still make three times that. He works on an assembly line with a boss yammering down his neck, sweating and dirty, while you work in an air-condiditoned office and telling people what to do. Let’s assume you didn’t earn a penny from age 18 to 34 (which isn’t true, but for illustrative purposes). And your friend was earning $100k a year in his cushy assembly line job (also not even close to true). That means he got a $1,600,000 head start on you. Now, assuming you both work another 30 years to age 65 (he will have to work longer, you most likely will retire sooner), you will earn 3 times what he does annually (remember we are assuming he earns $100k a year — in reality you probably earn 8-10 times what he does). When you are both done, he’s earned 4 million along the way and who knows how much in his nest egg to live out his life, and you’ve earned at least 9 million. $5,000,000 more than your friend. Oh, wait, let’s subtract out your student loans. O.k. $4,750,000 more than your friend (accounting for interest).
“I get 4 days off each month. I often work more than 80 hours a week. I take additional night call 2-3 nights a week; on those nights I get a phone call every 15 to 20 minutes and its back to work at 7am the next morning” — You and I and the rest of the world know that you will not be doing this schedule (albeit exaggerated and inflated) for the last 20 – 25 years of your career.
“When work is done, the day is done. No stress to take home.” — Except how he’s going to pay for his kids’ education, his mortgage, his bills, etc., on a meager $45,000 a year. No thanks!
“Who wants to trade with me?” — Yeah, who wants to make between $12,000,000 and $15,000,000 over their career? Apparently not the average American who will make about $2,000,000 over their career.
Please cut the “Whoa is me” crap.
cheers,
jj
By the way, please don’t operate on me with the little sleep you get. I (not you) would have to live with your mistake for life — if I still have a life. You have your malpractice insurance pay the suit and then go off on your vacation in the Carribbean.
I predict a huge upswing in the use of mid-levels (NPs and PAs) and, eventually, government-funded med school and residencies. You are right – no intelligent person will invest that much time and money to be a low-paid government drone.
I’ve been a NP for 16 years and I knew that forcing providers to accept Medicaid/Medicare was inevitable. Fewer and fewer providers are willing to take the often ridiculous reimbursements (esp. for high-risk pregnant patients who don’t keep appts or follow medical direction) so the only solution for the government is to use the force of law to provide care for these patients. To the leftists/socialists, doctors are just another flavor of the greedy rich (read kulaks) ripping off the workers.
The physicians were stupid. The government’s case had merit because the physicians were from *individual* practices. Had they banded together as one legal corporation that shared one central billing unit, they could have told the IIC and insurance companies to stick the fee schedule where the sun doesn’t shine. Problem solved.
Dr. Dazzle, I agree that the government’s case had merit. However, the chilling thing about the settlement was the requirement that these physicians now must accept contracts without any negotiation, and not threaten to leave. Does this mean that they are locked in for life? That’s not okay.
Intransition,
Please re-read the final judgement. There is no requirement that these physicians must accept contracts without any negotiation, nor is there any requirement that they cannot threaten to leave, INDIVIDUALLY speaking. As individuals they can do what they want, but when the group begins to collude, then that is illegal. It’s unfortunate that you fail to read the actual verbiage.
Hey, here’s an idea: Let’s have all the major insurers come together in a summit and collude together to not offer any type of health insurance to any indivudual or employer for anything less than $2,000 a month per individual. Sweet! Cash payments only because no one has insurance. Let physicians try to collect on self pay patients rather than insurance companies.
Or let’s let all gasoline distributors or even retailers collude together to not sell a gallon of gas for less than $10.00. That would be great for our economy. And then let’s have those governmental bastards say that the gas retailers must accept $3.00 per gallon without any negotiation.
Intransition,
The physicians colluded as a non-legal, non-business entity to fix prices and were punished accordingly by the anti-trust settlement. The article and responses highlight the fact that physicians are easily frightened into negotiating (and, for that matter, undercoding) from a self-perceived position of weakness. Unfortunately, physicians often seem to forget that, WITHOUT PHYSICIANS, THERE IS NO HEALTH CARE. Legal structures exist to allow physicians to leverage this realty. Had these physicians simply took the time to legally form a proper business entity, they could have bargained from a position of power, and rejected the insurance and government’s terms (which involves its own form of “price fixing”, ironically!)
Dr. Dazzle,
I don’t know if you are a real physician or not, but you hit the nail square on the head with your comment above. Physicians are the work horse of the healthcare system. No denying that. I wish they would even acknowledge a little bit that they need their Midlevels, Front desk folks, back-end people, and other pieces in the medical office. In some offices it’s like the physician walks on water while the rest of the office are lowly peons. In contrast, there are many offices where the physician is as gracious and kind as St. Peter.
I still don’t understand how this is a form of price fixing by the government, when the definition of price fixing involves multiple parties. Who is the state of Idaho WC board colluding with here?
cheers,
jj
Comment 1: By this precedent, it would seem that if the government offered to pay 50 cents for a hip replacement, not accepting it and complaining would expose the orthopedist to the full weight of Tony Holder’s federal lynch mob. Best to “opt out.” But what about the VOTERS who happen to need the hip replacements? Send them to the Department of Justice for help.
Comment 2: Worker’s Compensation is generally a pain. It’s in a world dominated by lawyers and “compensation neurotics.” In my experience, the low payment isn’t worth the paperwork hassle, so once again, I vote, “opt out.” But if everybody “opts out,” who’s going to take care of the poor guy who has a bona fide injury on the job? That’s easy. The Department of Justice can do it.
Agree 100%! Paperwork is a killer! I’ve stopped accepting WC.
“But if everybody “opts out,” who’s going to take care of the poor guy who has a bona fide injury on the job? That’s easy. The Department of Justice can do it.”
No, let’s just bring our economy to a screeching halt with a bunch of injured workers waiting to be seen.
That won’t happen for two reasons. First, it will never happen that eveybody opts out because if there is limited access, then WC will be able to pay higher rates with all their WC funds due to decreased volumes.
Second, employers will not wait for their employees to be queued in the limited physician supply line and pay extra for the medical services elsewhere. And to whom do you think the employers will pass along the cost? Yep, to you an I as consumers. Great! Now we have to pay $10.00 for a loaf of bread. Hey, but at least the physicians will be paid.
to those making stupid references to slavery, you should note that orthopedists rank way up there in the best reimbursed doctors, just below cardiologists. they have no other competition than podiatrists and chiropractors (who dine well off of the trash the ‘pods ignore). An hour of their time in the OR is paid at around the $1000/hr rate. They also spend about the least amount of time with patients, since their evaluation generally consists of a review of an xray or mri. If they are smart (which most are, since their residencies usually grab the cream of medical school classes) they have also bought into a radiology set up (so the xrays they order make them money) as well as the “surgericenter” they operate out of.
From what I remember in my jr high US history class, slavery was a little different.
Another history lesson: before Medicare, grandma’s broken hip and grandpa’s rusty knee were NOT paid for by anybody, so they did not get any fancy titanium joint replacements. They got traction (with bedsores and blood clots) and aspirin, and the orthopods got zip. Anyone who wants to do away with Medicare and thinks they will do better, is dreaming. And part of the problem with medicare and orthopedists is that while they “only” get $1500 for replacing a hip, the prosthesis costs something ridiculous, like $15-30000, and that does not include the hospital and anesthesia costs. Can you think of a better way to make sure only those patients that need it get it than to lower the pay for those who decide who needs it?
The problem with the current healthcare system in the US, from the perspective of this socialist surgeon, is that we cannot bargain collectively for our reimbursement, so the only options are to accept what the payors give you or to drop plans. While getting out of networks can work for the older. established, superspecialized uber-docs and their rich patients, it makes the out-of-network costs of care the patients’ responsibility, after they and their employer have done their part by paying premiums all along. How exactly is that fair?
Read most of comments and I want to present point of view of a physician with 15 years of experience in socialized medicine – in former USSR.
First, to make it clear, I’m against the healthcare reform and this particular “war on doctors” declared by DOJ.
But it may give you some comfort, let me desribe some aspects of our “happy socialized” future as I know it and it was not mentioned much before.
The drawbacks for general public is well known: rationing, shortage etc. But not for physicians!!!
The socialized enviroment brings up new kind of culture: collegiality becomes much more prominent. You will do more for the fellow physician, you’ll take him before all others etc.
You’ll work limited hours, you don’t have to think about preserving patient to make him come back by being more patient, smile, asking about his family etc. You’ll be GOD and they’ll beg you and they will pay you under the table to be seen, to have surgery etc. No malpractice!! Few examples: non-surgical specialist after max.years (20 years in practice) + board – earned 200 roubles/month. PhD would add another 50 and surgical specialist(no matter how many procedures) could add another 50. So, max. salary might be just 300/month or 3,600/year before taxes. The car sized as Honda Civic (no AC, no power windows, just radio – naked) costs about 10,000! And many doctors (and not only doctors) had a car! The healthcare was “a right” and free but EVERYONE paid!!!
Thank you very much!
So, if I understand this correctly-by not accepting the government’s price fix, doctors are price fixing and only the government can price fix because price fixing is illegal.
Given this debate, it’s somewhat amazing that Wyoming has recently accused spine surgeons of providing TOO much surgery.
Myself…….I’d prefer to do NO workman’s comp no matter what the price (well, if it was enough I’d make an exception) simply because of the unending paperwork and because everyone knows workman’s comp patients don’t do well…..and then you have to deal with that.
I’d rather take care of 20 self-employed farmers and get paid the same as 1 work-comp.
But despite all the years of school and training……and despite nobody giving MY small business a bail out; it seems that maybe I don’t get to choose?
Yeah, Mark. You da fool who wanted to help people. What were you thinking, man?
I’m a future orthopedic surgeon in the middle of a very rigorous and time consuming residency. In one of the posts above someone wrote the following:
“Take the following more extreme example: All emergency room doctors in the state get together, and refuse to work unless they are paid 10 times their current salary. Should that be allowed? Should they be allowed to hold people’s lives hostage to force huge increases in salary? ie “If you don’t pay me $1 million for bandaging you, I’ll let you die on the street”.
Example 2: Your house is on fire, and the fire department refuses to put out the fire unless you pay them $50,000. There, is, obviously, no competition to them. Is that OK too, in the name of capitalism?
If not, where do you draw the line?”
People who undergo training to become physicians and specialists like myself spend four years in college, four years in postgraduate school, amass $200K to $500K of debt, work for five additional years of training with 80-100 hour work weeks with 30 hour shifts (during which we get paid less than minimum wage per hour), take literally hundreds of exams, have to pay upwards of hundreds of thousands of dollars in yearly malpractice premiums. We have to sacrifice our social, family, and personal lives to have the privilege to work as an orthopedic surgeon or as a cardiologist. At the same time we have no right to negotiate with our employer medicare on better rates to stay in practice.
Somehow I have a feeling that if the government demanded that firefighters, postal workers, and police officers have to undergo eight years of school, amass $400K of debt, undergo 3-5 years of additional on the job training at 80 hr/wk, pay $80K in yearly malpractice premiums the numbers of people going into these professions would dwindle. I think that in the years to come the number and quality of physicians will also dwindle unless we change course.
“I think that in the years to come the number and quality of physicians will also dwindle unless we change course.”
What?! “Should that be allowed”? Surely we shouldn’t let intelligent people avoid entering the field of medicine and thus deprive us of essential services. Nay, these intelligent people, such as Udo, must be forced to enter the field!
Then again, given his reasoning ability, Udo would probably be exempt.
Sam, give me a freakin break. I love when doctors play the whole “woe is me” crap, because it
just shows how full of it they are.
First off, don’t figure in undergrad tuition for the cost of loans. Everyone has to deal with
undergrad tuition. The only reason med schools are so expensive is because doctor salaries are
so ridiculously overinflated. When you start out making 250k-300k, then med school costs are
NOTHING. Debt load is only relative to the ability to pay it back. Once we bring doctor salaries
down to reasonable amounts, med school tuitions will go down accordingly.
Secondly, residencies are paid VERY well, usually 40k-50k or more. This is more money than
the average American makes. So please quit complaining. Yes, you get paid less per hour,
but considering that’s it’s only a TRAINING PROGRAM, getting paid 50k/yr is pretty damn good.
Most people in the US don’t have the ability to make 50k/yr, even if they wanted to work more
hours. So consider yourself lucky. And also, knowing that you’re going to be making huge sums
of money after residency should be enough for you to stomach the “low” hourly wages.
And no, you don’t sacrifice your personal lives. All the residents I know are very social and
make lots of friends who are also fellow residents. You all have great social lives. And
whatever sacrifice you make to your family in time, you more than make up for bringning home those obscene salaries for the rest of your lives, being able to retire early, etc.
As for malpractice insurance, it is cheap and for most doctors it is paid for by their hospital
or practice. You still bring home huge sums of money.
I have friends who are doctors who talk to me honestly. And they all say that they have it GREAT. They get paid tons of money for relatively little work and infinite job security. Yes, you complain to the outside world about how hard it is, but that is only a smokescreen so people don’t actually realize that you guys are doing is overcharging the hell out of people and getting rich by bankrupting the American public with huge medical bills.
Doctors and hospitals have been scamming the American public for too long. We can do better. We WILL do better.
Jonathan,
My friend is a vascular surgeon. His wife tells him of several things (cell phone, etc) ‘just let the office pay for it’
She finally figured out that HE is the office. It’s still coming out of his salary. Any business person understands that.
I pay 30k yearly for malpractice insurance. It isn’t cheap.
Docbill,
First, let me say, I know MP insurance is not cheap. I cut the check for our orthopods every 6 months. I can’t say I feel your pain (I’m not a doc), I just can see it– it’s real.
However, if your friend’s business is properly set up, then he draws his salary irrespective of the profitability of the practice. It, along with cell phone bills (which he probably pays for his wife’s — although not related to his business), lunches, vehicle mileage, and other expenses are just that,, expenses and are written off. Great for lowering those taxes that we all pay. So, your friend draws a salary AND retains any addition profit (or loss) at the close of the fiscal year. There are a number of ways to set up a practice, so I will concede that this example might not be exactly the way your friend is set up, but the principles are the same.
cheers,
jj
Dr. Sam,
You do know it’s illegal for a resident to work more than 80 hours a week, right. You can sue your current employer.
Unless you are the exeption to every Orthopedic practice in the US. I doubt your practice payor mix is even 50% Medicare, which means the majority of your patients have payors with whom you negotiate rates — very lucrative rates and substantially higher than Medicare.
Doesn’t the age old adage say to sacrifice a little now for a lot later. A physician – and an orthopod to boot – will have no complaints as to their style of living for the last 50 years of life.
“Somehow I have a feeling that if the government demanded that firefighters, postal workers, and police officers have to undergo eight years of school, amass $400K of debt, undergo 3-5 years of additional on the job training at 80 hr/wk, pay $80K in yearly malpractice premiums the numbers of people going into these professions would dwindle.” — Really?? Do you even know what the annual ongoing training programs are for firefighters and policemen are? I wouldn’t mind taking a poll to see how many firefighters and policemen would rather make $250,000 – $300,000 a year (or in your case as an orthopedic surgeon — $400,000 to $700,000) a year for a minimal debt load and a few extra years in the profession. Oh, p.s., by the way, in the new deal firefighters don’t have to go into burning buildings and policemen won’t have to get shot at. They get to work in air conditioned offices and hospitals and demand every surgical tool and/or implant they want and walk around like they are the king of the office. Yes, let’s see how many policemen and firefighters would rather the current state.
cheers,
jj
You dont need any special skills to run into a burning building or shoot a gun.
You need a crapload of surgical skills to do an open reduction/internal fixation on a complex femur fracture. An orthopedic surgeon could easily do a fireman’s job with a little extra training. A fireman would have to start from scratch in order to do what an orthopedic surgeon does.
Hell, you can find good fireman/police straight out of high school with no additional training. Good luck recruiting an 18 year old to be a surgeon though.
Most surgeons do the same routine tasks and procedures over and over. You could easily train someone with half a brain to perform appendectomies by having them watch a few and learn the steps. It’s not that hard at all, it is only doctors who want to make it seem like what they do is soo complicated so they can justify the ridiculous rates they charge.
Good luck when you get sick. I’m sure when it’s you on the other end of the scalpel, you’ll be the first one to run off to places like Mayo Clinic. Think they’ll have any 18 year olds operating on you there?
Docbill,
Again, agree with you 100%. And the same could be said if we were in a burning building or being held hostage somewhere. I’m not sure the same could be said if I needed to go buy a new car. I am truly grateful for trained professionals when it comes to these life and death situations.
You certainly point out that when it comes to our health and the health of our loved ones, the “business” or “industry” is unique or at least different than most, if not all other markets in that we can’t do without.
It’s unfortunate that some in the industry (better said someone in all industries) will abuse this fact and/or their position which causes another law or regulation to come about.
cheers,
jj
“You dont need any special skills to run into a burning building or shoot a gun.”
LOL — I was a little hesitant to attempt to engage in an intelligent discussion with a pizza delivery boy with the username of his movie flick hero whose movie he’s seen 87 times and whose moves he practices in his parent’s garage, but then you make such a ridiculous statement like that above and it closed the deal. I (and I’m assuming most others) won’t be able to respect anything more your post nor will I attempt to reason with a fool. Guess you got the last word on this debate. Good job 8-ball.
jj
Doctor’s have been financially gangraping the American public for way too long. It’s about time the government step in and break up this medical cartel, a cartel that actually harms the health of American’s by limiting the supply of healthcare providers. Not to mention the obscenely overinflated medical bills that are the number one cause of bankrupcies in the United States. Oh, I guess “do no harm” doesn’t apply in that situation, right? What a flippin joke our medical system is.
I’m naive in thinking that doctors won’t find some other way to screw people over. But at least the corruption is being recognized.
You dont know anything about healthcare economics. Its not a free market, therefore increasing doctors wont lower costs. Thats why Boston and NYC, which have the HIGHEST number of doctors per capita in the world, also have the highest healthcare costs per capita in the world.
Manhattan/NYC has so many doctors that you can throw a stick and hit 5 doctor’s offices. Yet costs are still outrageously high there. Its because more doctors = more tests, more diagnoses, more chemotherapy, more cardiac caths, more MRIs, more everything.
Go ahead and pump out more doctors and watch healthcare costs skyrocket even higher than they are now. More doctors = higher healthcare costs, not lower. Dartmouth Atlas data proves that as a fundamental fact of our healthcare system.
Johnathan and Jason:
Since you are so concerned about how doctors are “gangraping” the public and since doctors have it oh-so-good, I’m puzzled as to why you haven’t entered the field of medicine, enabling you to both do well and do good.
Good question Bob.
I can’t speak for Johnathan and I don’t think I use quite the same venacular, but I will give you a few reasons for why I am not a surgeon.
1) I enjoy what I do and my compensation. I think some physicians should try to have the same perspective. I don’t complain about my situation and frankly could understand how someone would be put off if I was complaining, especially if that person knew me and my circumstances.
2) I choose not to be associated with a group that has been under fire as of late for corruption, complaining, and grandstanding. Of course there are many, many, many stand up physicians as I’m sure there is a lawyer or two out there with integrity (being facetious here of course). However, the profession becomes muddied when some in the profession with so much, perform questionable moral acts, complain about everything, and fein victim status.
3) I majored in Biology, scored a 32 on my MCAT, and was on the physician track. Then, I volunteered in a level one trauma center for a year while finishing my undergrad and beginning med school. My experience was horrible. It seemed like those docs hated their jobs and hated the patients. They almost seem put out when another patient came through the door. Always stressed out and angry and looking somewhere else for more money. I wanted to become a surgeon because I had the aptitude, I had the grades, and thought surgeons made a lot of money — I’m not going to lie. A wise anesthesiologist told me that if I was in the field of medicine for the money, I was in for the wrong reason and I could make more money with less stress elsewhere. He didn’t say surgeons didn’t make a lot of money, he just said that if that was my purpose, it woudn’t sustain me. Those E.R. docs were living proof of that fact and I could see myself turning into them. So I followed his advice and started my own opportunity.
4) Too much regulation and paperwork for me.
5) I felt I could do more community service, work, and public good through other charitable donation, activities, and events.
6) I wanted to be able to have the time to coach my kids’ sports teams, see them participate in concert recitals, and go on vacations for more than a week without having to worry about if my patient was being properly cared for.
I have been very fortunate and I feel like physicians need to count their blessings. People are putting their lives in the physicians hands and I shudder to think that the physician is more concerned about making $400k a year instead of $350k instead of the patients wellbeing.
Ahh, that was cathartic. Thanks, Bob.
“if I was in the field of medicine for the money, I was in for the wrong reason and I could make more money with less stress elsewhere.”
Y’know, I hear this statement all the time, but I don’t really see any truth in it. Doing a medical specialty is the easiest and more secure way to make a lot of money. Where else can you really be guaranteed to pull in 300k+ with infinite job stability? Finance/investment banking is no guarantee of such riches, and requires a lot of luck and timing. Neither is being a lawyer, nor is it “less stress.” Sure, maybe if you’re a company exec, but that’s not something you can really count on doing. Medicine is by far the easiest and most stable path to money.
How about a movie star? (O.k. now I am envious of some celebrities)
How about a PGA golf pro?
How about a Franchise owner of a successful chain?
How about a diamond importer?
How about Tony Little?
I’m not saying Medicine is easy and stress free. I give physicians their props. It just makes me cringe when they play the victim.
Oh come on. I’ve heard this same BS story a million times.
“yeah I scored a perfect 45 on my MCAT and won a Nobel prize. I got accepted to every medical school in the world but I’m turned them all down because I could be a far more noble person as an ambassador rather than a puny doctor”
Spare us the BS. You never took the MCAT, you never applied to med school because all of us know you are a loser and would never get accepted to any third tier trash MD program. You know absolutely nothing about medicine or healthcare, so please go back to your salesman job and STFU.
I think perhaps Card Check would assist these physicians. They could have an open ballot and tell everyone in Idaho they had chosen to unionize with associated collective bargaining benefits. I hate unions but if you’re going to beat them, do it at their own game.
Excuse me, but was Holder accusing the *government* of price fixing, or physicians? heh
Washington is so awful right now. They just have absolutely no respect for individual judgment or rights. Right out of Atlas Shrugged.
I have been following Dr. Janda’s articles for several years now and have found his info to be very enlightening. When are the citizens of the United States going to come to the realization that all the changes going on in this country are about control, absolute control, by gov’t over every aspect of the lives of the citizenry? It is time for an alliance to be established by those who understand what is a stake and will refuse collectively to comply. An ” ALLIANCE FOR NON-COMPLIANCE” if you will. Attempting to correct the direction of the country by simply playing the game according to rules laid out for us by the very folks that disregard all the rules when it is convenient forthem is absolute insanity. Healthcare/Obama-care is a great place to start! I know we already have the legal aspect of it being challenged, but I for one, would like to see a groundswell of support for informing the so-called powers that be that we don’t recognize them on this issue and will therefore, refuse to comply with any form of mandatory program. Our constitution has been repeatedly tramped on and it’s provisions ignored by our lawmakers, it is time to let them know, we know what those documents say, and that we’ll no longer stand still for any attmpt to stong-arm the citizenry into a Gov’t contolled socialist existence!
The guys in uniform being targeted is a fact, but they can use their brains to get good deals. Enjoy the car for a while and then get another one. Well I agree with Lt Dan, they are very young and lack the financial acumen for a great buy. Anyways second hand cars are sometime great buys if you know where to shop. You can check out in used car portals
.
Physicians in private practice cannot communicate with each other with the goal of initiating joint economic action. This is clearly a violation of long-standing law. The physicians would need to economically integrate their practices under a single corporate umbrella in order to communicate with each other about economic and contracting issues. This appears to be a case of naive physicians who have not received good legal advice.
Good article it’s really clear, i will try it! Very good article and blog, poker is good to !
- Clare JEFFREY
There is a major crisis happening right now and getting worse in American Health Care System.
The rising control of insurance companies and larger groups including hospital systems and so called IPAs and ACO or accountable care organizations. All these organized health care delivery structures emphasizes creating of monopolistic networks of care. These structures discriminate against solo practice physicians and they take away choice in patient care.
For example: a large hospital system buying medical practices to lock in their own referrals for hospitalization. Patients entering into these particular medical practices are only able to access their own designated hospitals. Illegal in all sense
IPA or Independent physician associations also emphasize monopoly since patients are only referred among each members outside referrals from this IPA structure would be minimal. Again
patients lose access to physicians outside of this IPA.
ACO or accountable care organizations. Another type of health care structure preventing access to patients to doctors outside of this particular ACOs.
We send troops abroad in the name of FREEDOM, but our congress is moving forwards in taking away freedom from us and from patients.
DOJ should investigate HMOs, IPAs and ACOs all involved in getting rid of competition or small solo practitioners!
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I worry that all this is happening at a time when the largest segment of our population will need this type of care the most.
A dear friend of ours is a doctor and we see him struggle to keep up with the crushing regulations and malpractice insurance premiums. Just because they are “doctors”, it doesn’t mean they don’t struggle with insurance bills like the rest of us.
With healthcare costs rising should we not be looking at preventative measures to reduce this issue?
Back pain is becoming something of normality in today’s society as our lifestyle dictates, and in some cases with dire consequences leaving an individual completely helpless. Work pressure and the onset of increasing age have a part to play in this problem area. http://www.sciatica-pains.com
helpful posts. I have read most of them and got a lot from them. To me, you are doing the great work .
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