21 June 2009


One of the great things about the blogosphere is that it has an inherently self-correcting mechanism -- when you put an opinion out there, especially if it is provocative and/or poorly-though-out, it's sure to draw some fire.  You have the choice of defending your opinions, revising your opinions or ignoring all criticism and losing credibility.   Given the controversial recommendation for reform I made, it's not particularly surprising that my op-ed contribution to the New York Times drew a lot of fire.

By the way, I'd like to thank the Times for giving me this opportunity to contribute; it was very humbling to be published on the same page alongside such accomplished and respected members of the health affairs community.  Thanks also to Kevin for recommending me; now I'm officially a member of the damned liberal media!   It was a fun exercise and very different from what I usually do.  The topic was assigned in advance, rather than just writing about whatever the hell I want, and there was a strict limit on length -- 400 words.  I went through multiple drafts and worked with their editor to bring it down to size and clarify some key thoughts for a general audience.  Working with an editor is really a rewarding experience, by the way.  Maybe I'll hire one for the blog.

There were over 300 comments on the op-ed (most not addressed to my bit): a lot of fodder for thought.  I'd like to respond to some of them here.

Just to clarify, the restrictions of the op-ed format did require substantial simplification of my central recommendation.  "The compensation for surgical procedures should be reduced, and the savings realized should be applied toward increasing pay for primary care physicians."  This reform is broadly stated and highly simplified.  This puts me in a situation like advocates of the infamous "public plan," in that it's easy to imagine it implemented in a worst-case way and attack it as wrongheaded, and difficult to defend it when the details are undefined.   To expand just a bit: I'm not in favor of a blanket restriction on the income of specialists or even an across-the-board reduction in the procedural RVUs.  I think the RVRBS is terribly flawed, however, and grossly overpays many (but not all) procedural services.  One solution to this would be to start over and re-think the physician work component of the RVRBS on a line-by-line basis.  With the current composition of the RUC, which is dominated by proceduralists, we would probably wind up with the same outcome.  However, if the RUC were rebalanced, giving each specialty representation according to the number of physicians practicing that specialty, it seems likely that the reweighted comittee would view physician work differently.  Anyway, it's tough to make a detailed argument for this to an audience who doesn't know anything about the RVRBS in 400 words, so simplification was necessary.

One point which the NYT elided over, by the way, was that I make no distinction when it comes to this proposal between surgeons and other specialists who are not surgeons per se but derive much of the income through procedures.  Most prominently, this would include cardiology and gastroenterology.  And while I use the shorthand "Specialists" for these folks, it's important to understand that many specialists do not perform many procedures at all (neurology, nephrology, etc).  Changing compensation for procedures would not affect them.

Ian derided as "risible" the distinction between "cognitive" and "procedural" services.  Certainly there is no implication that surgeons don't think!  However, this is common terminology distinguishing CPT codes which are medical from those which are related to a particular procedure.  Put more simply, the various E/M codes (Evaluation & Management) are the "cognitive" codes, and in fact many specialists rightly use those for their office consultations and other patient interactions which do not relate to a particular procedure.   Also, there was a suggestion that to propose policy changes in such a simplified format was somehow irresponsible.  I do not agree with this.   If my op-ed were influential beyond my wildest expectations, and my proposals were to gain actual momentum, that would be a good thing.  It's true that details would need to be added to ensure it was well-implemented; bad reform is worse than no reform.  Starting the conversation, however, is a necessary step to positive change and in no way is "reckless."

I think it's also important to be aware of the assumption under which we are operating: this is a zero-sum game.   In the current environment of increasing health care costs it is not realistic to expect that the amount of money available for physician compensation will increase. There is, at best, a fixed pool of money which must be divided up among doctors.  It would be nice if we could have painless rebalancing of physician income by paying PCPs a lot more without impacting the income of other physician.  But that's not where we are.  If doctors' pay is going to change, for each winner there must be a loser.  Similarly, I am assuming that the physician workforce will also remain more or less static -- that the number of doctors graduating every year from medical school (and IMGs) will not be drastically altered.  Many people say that we have a shortage of physicians, or that we are developing a shortage. I don't know.  But once again, in the zero-sum game, increasing the number of doctors practicing primary care medicine will necessarily reduce the number of doctors practicing specialty medicine.

There's no surprise that a proposition that the compensation of surgeons is too high evoked a highly defensive reaction from the surgeons who responded.  Just for reference, I have no intent to demean, belittle, or vilify individual docs or the contributions made by particular specialties.  All of us have a parochial feeling that "I work hard and I deserve the money I get."  Most of us have a firm belief that we have earned our compensation (and perhaps a little more) through our hard labor and sacrifices.  I'm no different.  At the policy level, we need to get over that blinkered perspective and make decisions based on whether or not they are good policy.  Within the confines of this discussion, the question is not "who deserves a certain level of pay," but "what incentives will this level of pay create, and are they the right incentives?"   I don't know how to quantify hard work and correlate that with compensation (many nurses I know have a much harder job than I do.)  There's no formula to relate the value created by a particular specialty with its reimbursement.  It is, however, easy to see that the US is grossly over-supplied in specialists; the logical solution for this is to redefine the economic incentives in a way that will amend that imbalance.

Also, I have no "Robin Hood" social justice motive for this proposal.  I don't care if an orthopod makes a ton more than I do.  My liberal sensibilities didn't drive this recommendation.  It's all about the incentives.

This does not mean that I think a surgeon and an internist should make the same amount of money.  Specialty training is hard and there should still be an incentive for some people to go into it.  The wild disparity in earning potential, however, is far beyond what is reasonable and should be reduced.  The typical family doc, pediatrician, or internist makes $90-150,000; it's not uncommon for specialists to make $500,000-$1,000,000.  The current system evolved with docs taking as much as they could get, which leaves unanswered the critical question of "how much is enough?" What's the critical threshold that would keep some docs in a given field, but encourage some who might have practiced specialty medicine to stay instead in primary care?

Some noted that Emergency Medicine is a well-compensated specialty, and implied that this somehow makes me a hypocrite.  Hardly -- depending on the technical details of implementation, my proposal could reduce the compensation for my field and get me lynched at the next Scientific Assembly.   I'm not volunteering for a pay cut and would not like it.  Emergency Medicine is important and all that, but it's still not primary care.  It strikes me as potentially good policy that my own specialty might be left out of any increase in "cognitive services" bonusing, and might possibly even lose income in the end.

A lot of the responses I've gotten are along the lines of "Don't you know that according to (my professional organization) there's already a shortage of (my specialty) and that if there aren't more of us we won't be able to provide enough of (my procedures)."  True enough.  There aren't enough ER docs, for that matter, at least according to ACEP.  I'll assume charitably that these studies should be taken at face value.  I agree that the specter of reducing access to any care, specialty or otherwise, is troubling.  Going back to the zero-sum game, however, there is already a critical shortage of docs in primary care specialties and there is already greatly limited access to primary care services, which will worsen if universal health insurance passes.  If it's an either-or, then there's no argument.   Primary care must come first.  

Maybe this is an argument for a markedly increased physician workforce, but I make that argument with hesitance.  Many other countries have more physicians per capita, but they also have markedly lower compensation for the average physician.  If we were to follow France's example and increase the number of physicians we have by 50%, that would dramatically increase the expense of physician services.  Can the already over-budget health care sector afford that?  Would policymakers respond by proportionately decreasing individual physician reimbursement?

If you've made it this far, thanks for reading.  I'm sure that I'm entirely adn tragically wrong and you all can make that clear for me in the comments.


  1. I think you published piece did a good job explaining the cognitive vs. procedure point well, especially to the non-medical reader.

  2. Although compensation in EM is quite good, it is somewhat insensitive to what the govt or insurance companies actually pay. I have seen net collections as a % of billings go from 70% in the early '80s to ~30%
    for the past 6-8 yrs. With these results, it is no wonder that many contracts require a hospital subsidy to be viable. Unless such subsidies are prohibited, EM pay is not likely to change much. There are a few hospitals where fee for service works well but even these are under pressure.

  3. I appreciate your clarifications and elaborations, many of which directly concern my earlier comments on the NYT site and here on your blog.

    Of course I don't agree with every (or even most!) of the counter-arguments you're making, but I feel as if I've said my piece, and any further discussion would be counter-productive. Plus, I've taken some time to read your blog and the other things you've written, and frankly you seem like a really great guy and now I feel bad about being somewhat hostile in my comments. So, sorry about that. I just feel very strongly that many of the problems highlighted in Gawande's article stem from physicians trying to eke out a better living in a climate of constricting reimbursements--that, basically, reduced physician pay has created this atmosphere of overspending. Further, I believe that physicians are about to get completely and totally screwed in this health care reform business, and the last thing we need is for anyone--particularly anyone in the medical community, which for its own good desperately needs to show solidarity right now--to suggest that there is a problem with physician/surgeon overcompensation, and that the solution is to take money away from anyone, even if it should ostensibly be given to some other group of physicians. Unfortunately, history has shown that this is never how it happens--physicians don't make more from Medicare/insurance; they only make less, and have more and more carved out of their livelihood. If anyone in government latches onto the idea that a group of physicians is growing fat in the current system, then you can bet that the next iteration will redress that boon, and probably many others, but most assuredly without any compensatory increase in another sector.

    Bottom line is I don't want to go through all of this training and debt-accruing, only to find myself in a new health care system in which I make the same type of money I made before medical school as a computer consultant. And I know that thousands of others feel the same, including pre-medical aged folks who will say "screw it" and go into law or business or some other field where the remuneration is commensurate with the effort.

    Anyhow, sorry for another long-winded post, and sorry again for any acrimony. I assure you that none remains on my end. You clearly have some great thoughts on the issue of health care reform, and you clearly care. I feel the same way myself. If you ever want to compare notes with somebody in another specialty, in (I promise!) a friendly and collaborative spirit, feel free to track me down at jocoserious at gmail dot com.

    Sorry, too, to hear about your cat. I wish you and your family the best.

    Best regards,

    Ian D.

  4. I am not sure how effectively decreasing the number of procedural specialists and increasing primary care would hold down cost, unless as a by-product of that event, access to care was limited by fiat. The cost of a product is usually determined the cost of production and delivery as well as demand. As an example, producing, delivering and implanting a knee joint replacement is a very expensive process, from the cost of R&D and skilled manufacturing, to the hospital OR where high tech equipment, anesthesia and drugs are used, to the post-op recovery unit and rehab unit, to the operating surgeon's (the installer's) fee, the surgical nurses and medical consultants, physical therapy and rehab devices such as crutches and walkers. Of all of these costs, the surgeons fee is a small but crucial fraction. Without the surgeon taking risk, paying high malpractice and working, there is no joint replacement. Without arbitrarily limiting access, I don't see that any decrease in patient demand for such a proven, life changing procedure is going to happen. How is simply decreasing the joint replacement surgeons fees and increasing the primary care doctors fees going to decrease societal demand for knee replacements, a high tech and expensive procedure?

  5. i posted the below comment on Ian's blog but thought it would also fit here. i agree that doctors' compensation must be a major part of the reform. the us medical education is probably the most expensive one in the world and the debt acquired after leaving the training is tantamount. this problem somehow should go away if we want great people to be drawn to medicine. however, i hope the financial compensation is not the primary reason for anyone committing to this eminent profession.

    "yeah, eternal ethical dilemma: fix an expensive disease regardless of its cost to the society or consider the impact to the society at large but let a valuable member of the society pass.

    this quandary has been keeping medical ethicists busy for ages. i believe the best solution is to let the society decide for themselves. for example the canadians voted for their kind of health care system referendum after referendum regardless of the consequences - such as waiting for treatment of elective problems, not having the option to use the most advanced technology lavishly hence letting their aging or 20 week newborn family member go. in some others, the well-to-do members of the society can enjoy the most advanced medical interventions while others have to settle with sub-standard services.

    yes, we have the best medicine that money can buy but at what cost? when and what is enough? is the health care system our greatest national priority so we can continue jacking up the cost to our detriment?

    everything has an opportunity cost. when we let the health care spending continue at its current expansion, we have to give up some other priorities, which might be the investments for technological advancement that made us the world leader (which currently keeps slipping from our reach).

    hard choices, not enough time and mental stamina to sort it all out..."

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