Wednesday, July 22, 2009

President: Doctors Consult Fee Schedules First

It came at 47 minutes or so in the President's press conference last night (bold emphasis mine):
We wanted to make sure that doctors are making decisions based on evidence, based on what works. That's not how it's happening right now. Doctors are forced to make decisions based on a fee payment schedule that's out there. So they're looking... if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, "I'd make a lot more money if I took this kids tonsils out." Now that might be the right thing to do, but I'd rather have that doctor making those decisions based on whether you need your kids tonsils out or whether it might make more sense to change, uh, maybe they have allergies or something else that would make a difference. So part of what we want to do is free doctors, patients, hospitals to make decisions based on what's best for patient care.
It is rare to see such hubris, such blatant disrespect of our profession by an individual on a national platform. It disregards the sacrifices doctors make every day on behalf of their patients. It speaks nothing to the requirements for learning our craft, the push to follow treatment guidelines crafted to improve care standards, about the recertification doctors must undergo every 10 years to remain credentialed and licensed, about the ever-present litigation risk that hovers over patient decisions and remains unscathed in the health care reform debate.

Now I admit, doctors have incentives to test, and test often, but that incentive is driven not by fee schedules, but assuring that no stone goes unturned and quality and comprehensive care assured. But more importantly, sometimes referring the patient for the expensive treatment is in the best interest of the patient: like referring a patient with three-vessel coronary disease for bypass surgery.

To think that the chief architech of health care reform in America feels this is how doctors make decisions is especially concerning. Now we know what we're up against.

But talking points aside, what is clear is that government officials have no place in attempting to proscribe the delivery of health care. With all due respect, politicians are not known for their honesty, humility, or trust-worthiness. Perhaps this colors their perception of another profession.

Mr. President, you owe America's doctors an apology.



Snarky Basterd said...

He owes the entire country an apology, Dr. Wes, but I'd be happy if he started with your profession.

(And, no, I'm not a real doc...just a doctor of sarcasm and satire.)

Chrysalis said...

You should mail this to him.

Keith said...


I once worked at a nother hospital where an EP doc took every patient he could get his hands on down to the lab to study them for arythmias. If you even mentioed you got lightheaded or dizzy once in your life, you had bought yourself an EP study. It is also well documented when physicians own the diagnostic equipment you tend to get more of the test that is being performed. How would you account for this consistent relationship?

I don't think this is blatant disrespect, but an acknowledgement that there are tests and procedures that are done that are further encouraged by a profit motive. The vast majority of docs try to do the right thing by their patients, but there needs to be some way to trim this fat out of the system. Insurance companies have tried to do it by increasing the hassle factor for patients and physicians, figuring if you really need that fancy test or expensive medication, making you jump through a bunch of beuracratic hoops will make you think twice.

Every solution is going to have some downside. The current system is not sustainable and does not offer good value for the money. Its fine to criticize, but what is your solution if you find such fault with the current changes on the table? How do you design a health care system that provides adequate care to all its members without bankrupting us all?

DrWes said...


There are bad apples in any profession. Your "one EP doc" story is anecdote, not data. The President's statements were globally reaching, said on a bully pulpit and implied that fee schedules drove decisions, not the patient's situation or needs. I disagree.

Further, you point out that peer review rarely works (why didn't you report that EP doctor to your professional staff???) - we should acknowledge this. But there are powerful legal reasons why doctors are hestitant to report their colleagues (slander, liable, and the time involved). But suggesting that most doctors consult fee schedules before making decisions is false and works to allientate the very people who will ultimately be responsible for delivering the care in our new health care system, whatever that may become.

While I have consistently agreed that rationing of health care services is necessary to control costs, I remain opposed to covert government or private rationing schemes that involve bureaucratic and corporate interests above those of our patients. Thoughtful rationing that occurs locally, based on sound clinical judgement and in concert with the patients themselves as they understand the cost/benefit ratios of the therapies proposed, is the only ethical choice we should support as doctors.

Jeffrey Parks MD FACS said...


Anonymous said...

The comment also shows how out of touch he is with reality. The only way to get to a specialist to have your child's tonsils removed is through your pediatrician. Wouldn't a greedy pediatrician want to keep you coming back over and over and over for all those sore throats?

Don't get me started on "allergy treatments".....

Keith said...


You are right! My example is anecdotal. But what isn't is the Dartmouth data that show wide variation in costs and use of certain procedures.

I did report this guy to my dept. chair, but the fact of the matter, the hospital was also making a ton of loot off his very expensive procedures, so everyone tended to turn a blind eye. I can also tell you about the GI doc that was getting referrals from a group of nursing home docs to do colonoscopies on these poor demented souls since they all had anemia.

You also did not explain why owners of diagnostic facilities tend to order more tests at them. If I was one of those beuracrats looking at these hard facts, I might draw the same conclusions our president is.

joegrind said...

I agree that you should be pissed and the medical profession should get a 'clarification' of his remarks. But what he did was give a three sentence summary of Dr. Gawande's lengthy article.
There are bad apples, but the system cannot remain the same.
I'm way too busy to go through the 1000 page House bill, but do any of the bills address any kind of malpractice 'reform'?

#1 Dinosaur said...

Amen. No more eloquent than you, sir.

shadowfax said...

Dude, you've turned into Olbermann!

"How dare you,sir! How DARE you!"

I've seen it over and over. The cardiologist who'll cath anything. The ER docs fighting over (insured) patients needing procedures. The surgeons who refuse to consult on patients with non-operative conditions within their specialty. Happens every friggin' day.

Docs are humans, and some are purer than others. But it's silly to feign outrage when it is pointed out that the incentives drive bad behavior and could use being fixed.

His biggest sin was having weak speech writers who couldn't come up with a more plausible clinical example.

Anonymous said...

Thank you so much Dr. Wes for calling out Obama. His contempt for our profession is so obvious. He loathes our payment schedule yet defends his wifes salary of $350k/yr as a mid level bureaucrat with no nights, weekends, call, liability, extended training. This is hypocrisy at its finest. Of all the waste in health care, the first finger is pointed at the doctors. I am outraged as I hope every physician should be. Our profession is under attack!

Happy oncologist said...

Long time reader, first time respopnde. Sorry, I'm a physician who's going to have to go with Keith on this, and I'm in a specialty, medical oncology, that is not unlike interventional cardiology, with a significant minority of practitioners blatantly favoring equivalent infusional drugs they make money off of over oral drugs, or who proffer drugs with minimal data for meaningful improvements in quality or length of life. I know it's partly a bad apple problem (McAllen, TX, anyone?), but it's a bed we've made as a profession-- there is no doubt about that-- and we are going to have to reckon wtih it. I have faith in you, Dr. Wes, that you are a bright academic practitioner with an evidence-based mindset (and probably not too significant volume incentives) but there is no doubt in my mind that caths are overdone in your profession, and even more so when there is financial incentive. Did Obama make the case a bit strongly to the exclusion of other sordid influences leading to medical inflation? Sure. But it is a point that needs to be reckoned with as a part of health insurance reform-- and if it comes at the expense of some salaries for cardiologists or medical oncologists, I am OK with that. (Disclaimer-- I'm in academia with absolutely no volume incentive :) )

DrWes said...

shadowfax and happy onc-

I've seen it over and over. The cardiologist who'll cath anything. The ER docs fighting over (insured) patients needing procedures. The surgeons who refuse to consult on patients with non-operative conditions within their specialty. Happens every friggin' day.

And I have seen nearly every ER doc do CT scans on patients with minor head lacerations before examining them, too. Does this mean they're simply greedy? Or might the threat of malpractice weigh more heavily than we dare admit on patient care choices? Maybe the threat of losing your appointment because you have not met a hospital's productivity milestones is the cause?

Yet, you stick with the greed argument and suggest that the government will fix personal behaviors.

Greed doesn't work that way.

Look, as we know, there are many reasons that contribute to our health care cost mess. But to imply that pediatricians are out there plucking tonsils from innocent children (or referring them for the procedure), just to make ends meet speaks to a fundamental problem with understanding of all of the contributing factors at hand and takes a disingenuous stab at our profession. God forbid we have an honest discussion about $6.5 million dollar verdicts awarded on the backs of attorneys channeling the thoughts of an unborn fetus and the effects that has on malpractice premiums, right?

But perhaps more ominously, to proclaim that "two-thirds of the cost of reform can be paid for by reallocating money that is simply being wasted in federal health care programs" - two thirds of a trillion dollars - is a misrepresentation potentially much more dangerous to the American people in the long run than wanton tonsillectomies.

Anonymous said...

Definition of an unnecessary cath: a cath done on some other patient. The whole story will be told when one of above accusors has a family member come to the ER with chest pain. The cath on their family member will not be unnecessary. These are finger pointing hypocrits. If any physician feels that a colleague is engaging in unsavory practices, they should report their behavior. Until that time, stop implying that I cath for greed.

Tex Bryant said...

There are many studies showing that health care costs vary widely by geographic region. It might be suspected that those with the highest expenditures might have the best health outcomes. The studies have shown that this not so. For instance, the Detroit region had in the past when the auto industry was humming a high per capita health expenditure, but it certainly didn't have the best outcomes in the nation. According to Dr. Stephen Schimpff, retired CEO of University of Maryland Medical Center, expenses rise by capacity in a region. That is, regions with the greatest concentration of specialists make use of these specialists consistently and thus have higher costs but not better outcomes. You can find a brief description of his findings at

Anonymous said...

Dr Wes,

As diffucult as it may seem and will be, something has to change..
The system is broke, both finacially and in it's delivery...
Dr wes, your in denial if you dont think that most of todays practices dont calculate their
treatment plan for the patient based on cost and reimbursement. Unfortuanately Obama used a poor choice as an example for this...He should have used the example of the
1/3 unnecessary ICDs going into
patients that will never derive any benefit...LOL...LONG LIVE MTWA...

Anonymous said...

You suggest that he has "reputation for understanding complex and highly nuanced situations". That's all he has. The reputation. I've not seen one shred of evidence for anything like the capacity for nuance or connecting complex dots since he was sworn in.

He's nothing but a self-aggrandizing nit; an ├╝ber-liberal, radically tainted, bought, sold, and paid for scion of the worst kind of politics this country has, so far, produced.

Anonymous said...

Look at tonsillectomy with a different perspective. 30 years ago, every kid had a tonsillectomy. Now, you rarely see tonsillectomies being performed. Physicians are unfairly targeted. We are soft targets. Obama is destroying the medical profession. Why not an apology to doctors and not the Cambridge Police department?

The Happy Hospitalist said...

Doctors must hold themselves accountable for their actions. There is nothing in the current fee for service delivery of health care that holds doctors accountable for their health care. Doctors who take advantage of that fact need to be vilified. The rest need to be applauded for their great care.

Anonymous said...

The Happy Hospitalist said:
"There is nothing in the current fee for service delivery of health care that holds doctors accountable for their health care".

WHAT!? Have you heard of Trial Lawyers, doctor? If you don't do every test/procedure and a bad outcome occurs, you can expect to be held accountable!

Look at the VA and Indian Health Service. They have salaried doctors. I suppose that those systems don't exceed their budgets every year. I just can't believe that doctors can be so clueless to buy into this obvious manipulation.

Physicians are so skeptical about RCTs but when it comes to some ivory tower liberal elistist who has never seen a patient more than once publishing garbage that doctors are evil and greedy, they buy right in. Come on, get a CLUE!

The Happy Hospitalist said...

So being accountable to lawyers. That's how you want to practice medicine?

Doctors set the standards of care. If you want to get sued for missing that 1 in a million head bleed in an altered mental status drug overdose because you didn't order the head CT just that once, I suggest you stop ordering a head CT on all of them and lower the bar for your local standards.

When you establish irrational standards out of fear, you are the problem, not the lawyers.

The lawyers are playing by the rules, just like the doctors are in this unaccountable fee for service system of ours.

Rogue Medic said...

Anonymous Fri Jul 24, 02:38:00 PM CDT,

He should have used the example of the 1/3 unnecessary ICDs going into patients that will never derive any benefit

If there is overuse of ICDs, you are not making a good case for it. Do you have any studies to cite?

1/3 unnecessary does not mean the same thing as never having paced or never having delivered a shock.

Would you say the same thing about an insurance policy that you pay money into, if you never file a claim. You could claim that you will never derive any benefit from insurance, unless you receive a payout.

Another consideration - without the ICD, would the patient be prescribed antiarrhythmic medication, for the rest of his/her life?

Rogue Medic said...


It is also well documented when physicians own the diagnostic equipment you tend to get more of the test that is being performed. How would you account for this consistent relationship?

There are many possible explanations. These are doctors, who are self-selecting. They are choosing to buy diagnostic equipment. One might deduce that the motivation of these doctors is largely driven by a belief in the need for these diagnostic procedures.

If you concluded that a diagnostic procedure is useful, or important, or underused, . . . you probably would use it significantly more often than a doctor, who did not come to the same conclusion about the value of this diagnostic procedure.

Are there any studies showing a change in the frequency of ordering procedures after purchasing the equipment. Then you also need to consider the availability of the equipment. Is the procedure being ordered more frequently, because it is much more convenient, if the equipment is on the premises? Has any major research come out in the mean time to encourage/discourage use of this particular diagnostic procedure? Are the doctors offering the diagnostic procedure at a lower cost than what was there before? Is the quality improved? Et cetera.

There are many things that go into the choice of treatments/diagnostic procedures. A good study will try to control for all of the variables that might affect those choices.

The media tend to publish the results of studies that have been promoted by people pushing their own agenda and a very simple message. Reality usually comes with different packaging.

Anonymous said...

The Happy Hospitalist believes that the doctors set the standards and not the lawyers.

WRONG! I just finished a legal case as the expert for the defense where the VA hospital was being sued. The doctors followed the guidelines that were designed by other doctors (not lawyers). The case settled! The doctors did everything right and they still lost money (sorry, you as a tax payer lost money). The lawyers have become the de facto writers of the guidelines.

PS The lawyers also make the rules under which we are sued. Which means that doctors lose.

PPS If you buy into the belief that the current fee for service delivery of health care is the problem, why is it that the VA and Indian health systems are always having budgeting issues. Those doctors are on salary. I anxiously await your reply.

Anonymous said...

Between the "doctors taking out tonsils when the patient has allergies" and the YouTube video of Obama telling a woman that maybe we can treat arrhythmias with pain medications, it's pretty obvious that this President is dangerously ignorant of how medicine works. The Republicans were already against his health reform proposals and many Democrats are also jumping ship. And the President has not endeared himself to the nation's physicians with his "expert" medical commentary.

Funny how running a campaign astutely and running an administration the same way seem to involve different skill sets with fairly little overlap.

The Happy Hospitalist said...

you're blaming doctors for settling the case? That sounds like you should be blaming the lawyers.

anon, I'm not sure what your beef is. The budgetary axe to the VA and the Indian Health has nothing to do with the bundled care model and everything to do with how it is funded.

One could argue right now that fee for service has killed primary care by axing it's revenue. That has nothing to do with fee for service and everything to do with the funding.

I'm saying we as a country could get a much better value for our tax dollar if we bundled care, put doctors in control of how to divy up the money and reward those doctors that practice quality medicine at a reasonable price.

The current model brings us uncontrolled health care inflation which is killing all of us. Because no one in fee for service is accountable to anyone.

At least in bundled care, physicians consider cost and quality in their pursuit of profit. Which, by the way, could be much bigger than it is now for doctors practicing cost effective quality medicine

Anonymous said...

Dear HH:
Here is the evolution of bundling. The payments begin at a reasonable level. As the new government bureaurcracy determines that hospitals are overbudget, the payments for each DRG are dropped. Let the cuts begin. By the way, you can have all the noncompliant CHF patients who like eating bags of chips. Those bounce backs are going to trigger red flags in Washington and some pencil pusher (getting paid more than you) will determine that you are a bad doctor. Get used to saying "patient X is killing my numbers".

Anonymous said...


It's not bad enough that a third party (Medicare, Medicaid, etc.) is between me and the 'paying' patient. Once bundling occurs, the hospital will get the payment and divide this among "providers". So, I will need to go begging to the hospital CEO for my reimbursement. Oh great, one more layer of bureaucracy to deal with. This is why physicians are some of the worst business people.

The Happy Hospitalist said...

Doc, my man, you are hung up on the payment part of the bundled care model. May I remind you that your field is getting decimated this year, and in the past year you yourself blogged about the reduced payment for multiple procedures on the same day.

And this is under fee for service.

What you have a problem with is how much the Medicare National Bank is paying you, not how they are paying you.

You seem to be worried that bundling the care will reduce the payment even more.

I can assure you, at 85 trillion dollars in the hole, Medicare will be paying far less in fee for service, perhaps pennies of what you are making now, unless we can slow the cost of health care inflation.

And fee for service certainly has been a massive failure in that regard.

The Happy Hospitalist said...

Dr Wes, that post was meant for anon, but feel free to comment if you wish.

DrWes said...


I think many doctors are concerned about who will get paid the "bundle." More and more doctors have become employees of larger hospital organizations, and as such, feel they'll be squeezed further as the health systems take their portion first, before distributing the paltry remains to the doctors.

For independent doctors, similar issues exist: will the government pay them a portion of the "bundle" directly? What, exactly, determines the amount a doctor gets paid? What will happen when a patient has more than one major medical illness? Will the doctors get paid only one "bundle" for the "major" illness or a portion of several "bundles" for each illness?

The "bundle" concept seems nice in theory, but practically it seems to be a disaster for doctors when it actually comes to implementing this payment rationing scheme.

The Happy Hospitalist said...

Bundling between primary MDs, subspecialists and hospitals and nursing homes and laboratories and radiology suites and ... generates efficiencies of scale that can generate profit through decreased operating costs.

What you fear is being left out of the profit equation. I'm here to tell you, that's happening right now, today, under fee for service.

This model is screwing all the great doctors who practice quality cost effective care. The only ones getting rich are the ones pretending to practice great medicine while cashing in on the Medicare National Bank.

If you are a great doctor, you should be thrilled to practice in a model that rewards your great care. If you are a pretend doctor, you will want to retire.

Anonymous said...

As the wife of a radiologist who has been in practice for 25 years, who practices in an underserved area, when I heard this comment, I was OUTraged. My husband puts the patient first in every interaction.
He gives up his personal life for his patients. He does more and more procedures every year for a sicker and sicker population and makes less and less to do it.
Dr. Wes, Obama owes you far more than an apology. Some of us know the truth. You are short staffed, overworked and maligned. You make less and less for more and more. I am disgusted and infuriated and would love to sit in a room with this President to have a beer....that I can throw in his face.

Lucky for Obama, if he gets sick, his Physician will do the right thing by him and give him great care. Even though what he deserves is a good spanking and a time out.

Anonymous said...

The "professional" thoughts on fees and their association with equipment suggests that Docs buy testing apparatus with the sole reason being to profit.

I have observed this as more of a desire to be "up to date" as in medicine various trends in testing drive the "need" for expensive equipment. This is especially true in hospitals where expenditures are in the millions. My physician is very up to date, but only needs modest and inexpensive testing apparatus. For more extensive testing he uses the hospital and in doing so "cost justifies" the larger expenditures for their equipment. On average every hospital has the equipment and none are "fully booked".

This discussion really takes the position that patients are no more than "test animals" and willingly go for repeated testing which accomplishes nothing for them and only increases profits for docs.

Our President not only impunes the professionalism of physicians but also that of the entire population of America. If one wants to see where the vast amount of money is lost, read the testimony of Malcolm Sparrow the governments expert on fraud on May 20 in front of the Senate Justice Committee on Crime [only Senator Spector was in attendance as all other members were attending a Presidential signing ceremony for fraud related Acts]. Sparrow estimates fraud to cost the US healthcare system $100 to $600 billion each year! Surely very little of this is from "over testing" by Docs!

More to the point if recoveries were made they would restore $1 to $6 Trillion over 10 years.

Does anyone really want a way to finance "Healthcare for All" which lowers the National debt???