Doctors' Incomes Not Aligned With Patient Care Provided

Back when I started practice in the 1960's, plastic surgeons took care of burn patients, chronic leg ulcers and scars. They did a few face lifts and boob jobs but that was not their main source of income. Dermatologist did almost no cosmetic procedures. Skin peels, Botox, hair transplants and the like came along much later. As third party payers (i.e. private insurers and government programs) became more prominent, they clamped down on escalating cost of medical fees.

Doctors searched for other sources of income. Few generalist and specialist could shift to private pay services but plastic surgeons and dermatologist could . . . and they did! So did some of the non-cosmetic physicians like ENT and OB/Gyn docs. Now, many are transplanting hair and performing liposuction. Every one of them that took this route rely on cosmetic procedures, paid for out of the patient's pocket, for much -if not most- of their income.

There is nothing wrong with this, I guess, as long as everyone understands: dermatologist now average two times more annual income or pediatricians. In other words, doctors who work 90 to a 100 hours a week taking care of sick children make less than $100,000 a year while dermatologists, who have virtually no night calls, sneer at an offer of $200,000 a year. Does that sound right to you?

Back in the days before Medicare and private health insurance (yes, there was such a time) patients paid for their own care. A combination of things made this nearly impossible. For one thing, sophisticated procedures, diagnostic test and treatments were invented that proved to be very expensive. People could actually be cured of diseases formally thought untreatable so they had to find a way of affording that care.

The solution was insurance or socialized medicine (Medicare). After considerable debate, the Medicare Bill was passed to take care of the elderly but health care for the rest of the population was left to private enterprise. This created a whole new industry.

For a long while, doctors thought it was great. We saw a patient, billed the insurance company and got paid. There was just one problem - no self-control. Patients could be seen for the slightest thing, doctors could treat with the most expensive procedure and set whatever price they wanted without debate. The costs spiraled out of control and rules were imposed to put a cap on it. This included a very complicated list of procedural codes designed to convey the services rendered to a patient. That only resulted in game-playing and chicanery.

For example, over my last 20 years in practice, it was not uncommon to go to a medical education meeting where one or more of the topics was on techniques to code procedures in order to get paid more.

Thus began the long trail that leads to where we are today - a major economic and social mess. Virtually a forth of the U.S. population gets little or no health care, medical specialists get rich yet whine about their plight, and primary care doctors, who work the hardest, barely get by.

What's the solution? There are as many answers as there are experts. I'm no expert so I'm not going to add to the confusion. However, let me make it clear, to do nothing is not the answer. It is time for action and that should be your message when you communicate with your representatives in Washington.