Wednesday, September 10, 2008

More on Doctors vs. Lawyers

Well, I've previously commented on the preponderance of donations to the presidential campaigns by lawyers versus doctors, but today, I'd thought I'd turn to a different issue: the striking differences each profession uses for billing those they serve.

Recently, I have had the misfortune of requiring the services of some of my more esteemed members of the legal profession. My faithful readers will be happy to know that it has nothing to do with malpractice, but it does have to do with this blog. Rest assured I will be more forthcoming in future weeks about the situation, but for now, especially after learning when not to blog about legal proceedings thanks to the misfortune of fellow-blogger, Flea, I will table any discussion regarding my circumstances.

But that does not mean I can’t speak about what I have learned from my lawyers, especially about how their billing practices differ from doctors’ billing practices. To say I am envious how they conduct business is an understatement. For when it comes to accounts receivable, lawyers rock. (I can’t believe I’m saying this, but it’s true).

So here are the differences I have realized so far:
  • Lawyers work in their offices, then travel to court rooms, billing for their travel expenses there. Doctors work in their offices and travel to hospitals. They drive their own car to the hospital and pay for gas that is not reimbursed.

  • Courtrooms do not bill patients or lawyers. Hospitals always bill patients.

  • Lawyers bill by the hour. Doctors bill by the procedure.

  • Anyone can see a lawyer, but they'll have to pay for it. Anyone can see a doctor at anytime (can you say ER?) without concern of having to pay for it.

  • Senior law partners make $595 per hour and junior law partners make $395 per hour. This pays for their expertise, office expenses, including personnel, etc. Doctors are paid irrespective to experience and are paid much less than lawyers, but few really know what their hourly wage is because it differs from patient to patient and procedure to procedure, based on the patient’s insurance plan.

  • Lawyers do not accept partial payment from their clients. With the exception of most plastic surgeons and some dermatologists who are cash-only, most doctors must accept partial payment from their patients based on pre-negotiated agreements with insurers as payment in full.

  • Lawyers divide their hour in 0.1 increments (6 minutes) and bill for work accordingly (the smallest time I was billed for was 0.2 hr – 12 minutes). We must work for over 20 minutes to move to a level “2” evaluation from a simpler, level “1” evaluation.

  • Lawyers bill for conversations, research, phone calls, meetings at the same rate as they do for being in court. Doctors’ do not bill for time spent discussing cases, research, phone calls, or meetings – their income comes from “bundling” of a single Medicare payment from their time before and during surgery.

  • Lawyers continue to bill for additional services rendered after being in court. Doctors cannot bill for any evaluation of a patient after surgery for 90 days, lest they be prosecuted by Medicare for “double-dipping.”

  • Lawyers describe the service rendered and bill for it based solely on the time required to complete the task. Doctors can describe and describe their service until their blue in the face, but unless they add a family history, 12 elements of a review of systems, do 15 back flips and thirty push-ups, they cannot bill a level “5” consult.

  • If lawyers do not get paid, they sue you directly. (God help you.) If a doctor does not get paid, doctors either write off the loss or pay for a collection service to hound you or sue you and, if lucky, receive 60% of the amount due.

In summary, lawyers set their own value, guard it carefully, and increase their hourly wage based on reputation, supply, and demand. Doctors, on the other hand, have succumbed to socialist pressures that have prevented a more realistic, capitalist approach to their economics. As such, they have allowed their value to be set for them by others and have watched their market value (and any ability to negotiate their value going forward) to dwindle, irrespective of specialty.

No wonder there’s a doctor shortage looming.



Anonymous said...

Dear Dr. Fisher,
I am so sorry to hear about this. Please know you have the support of lots of your fellow medical professional bloggers who greatly respect and admire your work and your blog. Keep us posted and hang in there!

#1 Dinosaur said...

The solution seems so obvious.

rlbates said...

This is a wonderful post. I sure hope you will continue writing your blog for a long time to come. Take care.

Desperate Mother's call for help... said...

A desperate mother's call for help.....

Three children (5 year old girl, 7 year old boy, and an 8 year old girl) living in Connecticut are being separated from the only family they know, their mother Ysabel Contreras, who recently was advised that she will be deported to Peru due to the dysfunction and complexity of our immigration laws.

Ysabel Contreras came to this country like many other immigrants looking for a better future. Residing 13 years in Connecticut she married and had three beautiful kids, a 5 year old girl, a 7 year old boy, and an 8 year old girl. Ysabel is a hard worker, honest mother, she has good morals, is respected by her community, and raises her children likewise. She was recently informed that she will be deported to Peru on September 22, 2008 and will never be able to return to the United States. Can you even imagine receiving such news? What her children are going through? Who will care for them, the way only a mother can? Just for a moment put yourself in her shoes, and try to sympathize with what this poor woman has to face.

As a community and as parents this family needs your “HELP”, they only have one final attempt to file one last appeal to the Federal Government so that Ysabel won’t be taken away from her children and the dignified, honest life she worked so hard to provide for them. They are attempting to file an appeal with the Federal Courts; however, the Attorney fees alone are $7,000.00. We ask anyone who has a family or has experienced anything like Ysabel and her family, to please find it in your hearts to help them for this cause. Anything you can contribute is greatly appreciated!

God bless you all and keep Ysabel and her family in your prayers.

You can contact any of the following people below with donations and/or questions.

Angie Martinez @ 860-712-3123

Diana Barriga @ 860-830-6093

Elizabeth Marrero @ 860-810-5150

Also, any information in regards to skilled attorneys that handle immigration cases with the Second Circuit Court would be appreciated.

Whatever you do to the least of my brothers, that you do unto me ... .Matthew 25:40

Anonymous said...

The shortage of doctors is artificially created by restricting admission to medschools, and then limited slots available for residencies for different specialties.

There are other benefits of being a doctor, the respect and admiration from the general public, and you would never get the same from the public regarding our "more esteemed members of the legal profession." We all can benefit from a better compensation model, but you don't and rarely if ever get an itemized list of procedures with cost from any doctor before receiving care. Would you like to conduct your work like an auto-mechanic?

Anonymous said...

Does this mean you're going to law school?

Michael Rack, MD said...

Desperate Mother, why don't the children just go to Peru with their mother? If they desire, since they are US citizens, they can come back to the US as adults.

Justin said...

One of the major grievances I have with medical reimbursement is that there is no tie between results and compensation. The top earning doctors make top dollar by being brutally efficient with their patients, not by being good doctors.

Justin said...

And to further substantiate your doctor shortage, medical students are leaving medicine left and right. I've started the MBA portion of my dual degree program, and venture capital is looking far more attractive.

Don't get me wrong, I love medicine, I love surgery, I love being in the OR during a cardiothoracic case and seeing the human heart in front of me burst back to its beautiful rhythm after a CABG, and most of all I love my patients, but there are so many questions in my mind about being a doctor that just are not being answered to my satisfaction.

Anonymous said...

Question - how did doctors allow themselves to give up their ability to independently bill? When did it happen? It wasn't always this way. Who among you thought it was a good idea?

Roy M. Poses MD said...

A great post, but you didn't explain how the nutty fee for service pay schedule imposed on us by Medicare, with the acquiescence of nearly all managed care organizations and health insurers, is a product of Medicare's collaboration with the mysterious AMA-sponsored RUC (RBRVS Update Committee). See:

Anonymous said...

The answer to this discrepancy is simple: the public and the politicians consider healthcare a "right" or at the very least an extremely valuable commodity. They dont consider access to a lawyer to be that valuable.

Thats why you never hear a politician stump about how poor Ms Edwards cant find a lawyer to take her case. Because nobody cares if a lawyer wont take her case.

However, you tell a sad story about how Ms Edwards has cancer and cant find a doctor, then the whole world whines and mashes teeth and demands that the federal govt gets involved.

Legal profession is a free market because its not valued as a "right" by the public and politicians. Change this attitude, and you'll see medicine and law become very similar.

Anonymous said...

BTW, there's no shortage of doctors, and more doctors = HIGHER healthcare costs, not lower.

Consider NYC. NYC has the highest concentration of docs per capita in the world. Yet they also have the highest healthcare costs per capita in the world. More doctors = patient scavenging, more procedures, etc. Healthcare does not operate like a free market so flooding the country with doctors will make per capita costs go UP, not down.

The USA has too many doctors, not too few. Far too many cardiologists doing echos and caths/stents on people who dont really need them.

Its no secret that artery blockages get cathed/stented in NYC at a rate thats TRIPLE the rest of the country, yet cardiac outcomes are the same. There's an inverse relationship between the % of blockage in an artery vs the likelihood of getting stented depending on which part of the country you live in. In NYC, cardiologists stent at much lower blockage % compared to other parts of the country that dont have so many cardiologists running around.

SeaSpray said...

Post and comments most interesting.

Anonymous said...

Anonymous said........Would you like to conduct your work like an auto-mechanic?

Yeah, Anonymous, the auto mechanic charges $90 just to open the hood on my Ford and 'look at the problem.' For a physician the Medicare payment for an 15 minute office visit is only about $50.

Let's see mechanic school versus a physician's training of a College Degree (4 years), Medical School (4 years), internship and residency (3-7 years)...that's 11 to 15 years of secondary/graduate education.

Yep you are right things SHOULD BE DIFFERENT!

Anonymous said...

The legal profession is also more entrepreneurial. This can be good and it can be bad.

On the good side, some attorneys can find that one tort case that settles for millions resulting in more money than most GP's or even specialists will make in a life time.

On the bad side, this forces attorney to constantly market themselves in a do or die legal market.

In sum, the entrepreneurial aspect of law sees no cap on incomes. However, most lawyers (unlike physicians) cannot be guaranteed at least $100,000 salary per year. You get and you give.

Anonymous said...

i disagree, nothing should be worth more than saving people's lives. in that perspective, a doctor's job is one of the best jobs u could have.

Alicia said...

It seems like everyone here agrees things should be changed--but how do we go about changing them is the question? Shouldn't we work on getting rid of he middle men (the hmos, the insurers) and just work on a single payer system where things are simpler, much less drowning in paperwork, etc. the PNHP organization ( physicians for a national healthcare plan) has the right approach an is actually doing things to change rather than just

Anonymous said...

The anonymous post that their is no doctor shortage is too simplistic a statement. We have too few primary care doctors. Keeping people out of the interventional suites is not regarded by insurers or the public as anything glamorous to do. Medical students who choose primary care have the same medical school costs as the ones who choose highly reimbursed subspecialties--they just take longer to pay them off. Interestingly enough, the studies which have been done show that a larger percentage of primary care physicians in a population actually decreases medical costs. If we really want to reduce medical costs, we should try to remove the disincentive to practice primary care medicine. Systems generally deliver the results they are designed to deliver.

I do sympathize with the comparison with attorneys. I've also worked with them and find their system amazing and not altogether comfortable.