Doctors & Money: The Last Three Piggies

Roast Beef, Bankruptcy, and Happiness

To round out our group of Piggies I thought that the last three sort of go together. These three Piggies may very well be at the center of how doctors are actually behaving and may give us all some insight into the future of how we will all get our healthcare in the coming years.

The Beef Eaters: Who really is the Piggy that had roast beef?

While much of the public tries to grasp onto the erroneous idea that all doctors do extraordinarily well financially this is clearly not the case. This I showed in the first Piggy that went to market. Read that. Twice. There are many doctors who do VERY well financially, though. We can define the financial winners (roast beef eaters) into three groups:

1. The doctors that work their butts off 90 hours a week and run efficient offices.


2. The doctors who are in specialties that are more involved in cosmetic aspects of medicine who built large factories of delivery of cosmetic care.


3. The doctors who decided to remove themselves from all insurance plans and charge high rates for their services.

I am sure there are more groups but these represent the majority. Please feel free to blog on some more.

Let's look at these three groups not as much to make value judgments but to see if we can learn something from their effects on health care in general and our own health in particular.

I know many doctors who work very long hours, take a healthy number of health plans to assure diversity in their patient population and commitment to their community, charge reasonable rates for patients in plans they choose not to take and run the best offices they can. Take pictures of these doctors the next time you see them. Put them in the next space capsule so that future generations will know who they were. They are dead and but they don't know it yet. They will not be coming back. Count on seeing a Tyrannosaurus Rex before you see one of these dudes walking down the hall.

The cosmetic doctors and surgeons are neither doctors nor surgeons IF they are practicing their craft for the sake of vanity. Don't even try to convince me that they are doing anything good in the world concerning the self-image of those they operate on. That motivation affects less than 5% of plastic surgeons. The other 95% are hairdressers with licenses to hold scalpels instead of barber shears. They will make a lot of money (and eat a lot of roast beef) because we are a society consumed by youth and beauty. They are not surgeons. They just don't count when discussing medicine. End discussion. I laugh when I hear of a prominent Hollywood Plastic Surgeon. What a joke. Prominent for what? Saving lives - NOT. Helping the health of others - NOT. Making some already fathead actress have even puffier lips. If we define prominence based on that we are surely are on the road to perdition.

There is a third group that is more controversial and represents those most difficult aspects of the money crisis facing doctors. These are doctors who truly do outstanding medicine and surgery and decide to be out of all insurance plans and charge what they feel they should get for their services. This is difficult in that on the one hand I highly support their personal choices to charge what they want for their services. The problem is that, over time, only a select few in the population will be able to afford them. This means the truly best and the brightest will be treating rich people from Beverly Hills and Park Avenue and no one else.

Let's make this clear. The fault is not in the talented doctors that want to charge what they choose to but rather in that we do not have an insurance system that can even pay a pediatrician for a flu vaccine in a timely manner let alone complex brain surgery. This third group is the one that is growing most rapidly.

As general physicians, specialists and surgeons get more in demand it is only natural they will leave the insurance plans that offer below market pay, extra paperwork, and interference with decision making. This group will continue to grow and what will be left you will not want to operate on your worst enemy. It is already happening. If you are a patient in one of these large multi-medical groups that mixes primary care doctors and surgeons and you think that the surgeon in the group is the best one in the community then wake up. Of course not - it is the surgeon that the medical doctors hired to make money from. The better doctors went off to eat roast beef and you are the meat that is left for the surgeons in the multispecialty groups. This would be a good time to eat cake.

This brings us to our fourth Piggy: This Piggy Had None

In the war between insurers and insurers and insurers and more insurers with pharmaceutical and device manufacturers and politicians there will be casualties of this war. Patient health is one. For the purposes of this post the casualty will be good and well-meaning medical practices. They will not have roast beef. They will not even have liverwurst. They will have none. They will go bankrupt. They are the roadkill on the highway of health.

In the last five years alone I have seen countless 1-5 person medical groups close their doors for a variety of reasons. Some because they can't keep up with the expenses. Some because the paperwork and administrative time to practice is just not worth it. Others because the numbers don't add up after the 90th hour of work. Where did they go? Some joined multi-specialty groups for the "protection amongst the many" philosophy. I view this as temporary salvation as they are probably becoming medical refugees in large refugee camps until the insurance companies and politicians create havoc for these groups. Some have taken full-time salary positions for hospitals. This can be a great thing for a forward thinking hospital and a bonus to the physician but it does represent a change in the level of service and personalization. Others, if they are of a certain age, just decided to retire. The great sadness of the death of the smaller groups is that they were the backbone of service and dedication that made American medicine great. Without these groups we are becoming a bit more of an assembly line of medical practice.

So what will make doctors happy when it comes to payment and job dedication? Will we ever see the day when:

This Piggy cried wee, wee, wee all the way home.

Happiness is subjective. In this current medical environment represented by our five Piggies it is hard to determine what the mix should be. If money makes you happy then become a beef-eating plastic surgeon (medical beautician). If what you want is that amazing dedication type job but need to make more money and can't work 80 hours a week then you will surely stay home, work for a private equity firm, and cry wee, wee, wee for the rest of your days but you will not be a Dr. Piggy and the world will be without you as a talented Surgeon Piggy. If you are that good in medicine and charge a retail rate for your surgery you will be driving that great big car but all your patients will be industry fat cats. You will soon ask the question: Did I go into medicine to only treat the top 5% of the economic scale?

What will allow this Piggy to be happy and cry wee, wee, wee all the way home? From what I hear from my colleagues here are some of the major things that doctors would like to see happen in medicine:

1. When a patient comes to the office for a service and that service gets rendered then the service gets paid. There are no denials by the insurance company for any of their classically lame reasons like- "we want more documentation," or "we are sending the bill for medical review."


2. There absolutely needs to be serious reform of medical malpractice. I support caps on liability that have been in the State of Illinois for the past few years where the most a person can receive is 500K for an adult case and 1 million for a pediatric case. I also think there needs to be a state medical review that would allow a case to even go to a trial jury.


3. If we ever do get to a universal insurance model there should be two options of participation: (a) complete joining by the doctor with payment of medical malpractice for those that accept the universal insurance and (b) joining partially where the doctor gets the universal payment but is allowed to charge any amount over that (no payment of this doctor's medical malpractice). This may assure a wide range of providers. Possibly.


4. Allow doctors to partner with hospitals where hospitals can pick up certain costs like malpractice, office equipment and maybe even central scheduling or supplying of office workers. Currently these kinds of partnerships are illegal.


5. Dismantle the entire private insurance industry. It is a failed model. Notice how I just sort of snuck that last one in...
   

It is unlikely that any of the above recommendations will even be remotely followed because generally speaking the free market will determine what happens. Smart Piggies will find out they will not get their value in medicine; they will seek other fields leaving a certain lesser-quality pool behind. That pool will be further diluted because the smartest Piggies left will go for the roast beef medical jobs and careers leaving whomever is left to be your and my doctor. That person will be our doctor for 3-5 years and then starve from the lack of any roast beef at all as they are the Piggies who had none. They will leave for other types of pastures. The few good souls who remain will not cry wee, wee, wee all the way home. They will just be crying during the eulogy service for the death of American medicine.

Oink.

Doctor K.

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