Another Letter to Washington, from a Physician on the Front Lines.

-by Matthew Moeller.

Due to the tremendous popularity of Dr. Moeller’s original post as well as some of the critiques and questions it raised, Dr. Moeller has written this follow-up post in response.

Thank you to everyone for the positive feedback. Over 57,000 Facebook “likes”, tweets, and newspaper requests over the past week was quite a surprise. I was especially moved by the multiple tweets from hospices, physician groups, and individuals recommending my article. This article really has hit a nerve and shed light on some of the issues at hand in today’s healthcare debate. I am writing a follow up article to further address some issues.

First, I wrote my original letter to illustrate some sacrifices doctors on the front lines of care make. In order for doctors to continue providing the highest quality comprehensive care, we need our leaders/ lawmakers to understand the perspective we face so that the best solution can be found to care for our population. I do not feel that this particular perspective was voiced on Capitol Hill during the health care reform debate. Yes, there are lobbyists, but they are not those who are treating patients and may not know the nuances that individual doctors can provide. In addition, I am concerned about my colleagues in private practice (specialists or primary care doctors) whose livelihood is threatened because of the potential cuts in reimbursement (up to 26%). This measure could force these doctors out of practice simply because their expenses (which rise yearly) are exceeding their declining reimbursement, which has declined steadily over the past several years already. If this does happen, it may force doctors to stop seeing Medicare patients because reimbursement is usually lowest for this group. It will take away the physician-patient relationship that is needed for great medical care. A recent Forbes article explains this. In my opinion, Congress needs the help of doctors who take care of patients daily to give their advice on possible remedies.

Despite these lingering issues, I nevertheless love my profession and my patients. Becoming a doctor was the right choice for me; I was interested in science since I was a little kid and am thankful that I can use my education to help my patients and their families. I have also learned a tremendous amount from my patients. I cannot see myself practicing any other field other than medicine and I am humbled daily serving my patients. I definitely would do it all over again as well because I feel this profession is my calling and I get an enormous amount of personal satisfaction taking care of those in need. Anyways, who would go into medicine in the first place with its long hours, large debt load, delayed earnings, risk of lawsuits, and daily life and death decisions if they didn’t true care about the human race? I am happy to say that most of my colleagues feel the same way. Our concerns rest on the idea that we may not be able to provide quality care to all patients if the tools and resources we need are reduced.

Second, I was trying to speak for ALL doctors, not just GI doctors. People have commented that I was complaining about my salary and the salary of GI doctors. This article was not intended for GI physicians, but, rather, for all physicians. Not all physicians get paid the same and primary care doctors typically get paid significantly less than specialists. The article was a personal anecdote to illustrate some sacrifices of a typical doctor who is paying off his or her loans themselves. I am not complaining about my current compensation. Doctors do have the highest average salary of any other profession despite the financial sacrifices early in our career. But I am concerned about the FUTURE CUTS that may force doctors to

either stop seeing Medicare patients or encourage them to do concierge medicine (which charges a premium to patients for access to the doctor). I have this concern because most of my colleagues in practices have seen their reimbursement cut and their expenses increase. When these two things happen, one either works more hours in the week to make up the difference or their expenses increase until they can no longer afford to see patients without going into debt. This in turn could lead to the decline of quality advanced health care that Americans enjoy. There are numerous articles out there as well that show concierge medicine is growing).

The way doctors currently get reimbursed is unique to the medical profession. The charges (bills) that patients see in the mail are not what doctors get paid. These are inflated numbers derived from contracts between hospitals or groups and insurance companies. When a hospital or doctor submits a charge (bill), the insurance companies or Medicare/Medicaid depending on the patient’s insurance utilize a fee schedule, which consists of thousands of codes that give dollar amounts for individual procedures or clinic visits (available on AMA website). Each code has a dollar figure and a relative value unit (RVU) to determine how much to reimburse that doctor. This is called a “Medicare fee schedule” and insurance companies will pay a certain percentage of the fee based on Medicare. This can range from 80% to 180% of Medicare depending on the insurance carrier. If a patient has Medicare, however, one can see exactly what that doctor will get paid based on the CPT code (it varies 1% based on geography) by using the fee schedule. This is often called the “allowable charge” in patient’s bills. The revenue the doctor receives is in fact this fee (not the charge) and is set no matter how much the hospital or doctor chooses to charge. To complicate matters, there are usually two different charges in a patient’s bill: a “professional” charge from the doctor, and a “facility or hospital” charge (an inflated charge that only goes to the facility or the hospital, not the doctor). First, the doctor only sees the “professional charge” (not the hospital charge) if he or she works for a hospital. This is the charge for the doctors’ services (e.g. office visit vs. procedure vs. MRI interpretation). Second, the doctor only receives a fraction of this “professional charge” because this is reduced by the fee schedule to the appropriate amount. After all of this, a doctor sees only a small fraction of the original charge (the bill the patient may see) and this does not include overhead expenses the practice incurs (which can range from 30 to 60%). This above explanation is not understood by our leaders (ie. President Obama) as verified in this video discussing foot amputations in diabetics.

President Obama claimed that surgeons get paid (not charged) “30, 40, 50 thousand dollars” for a foot amputation. Looking at the Medicare Fee schedule, CPT code 28805 states that the surgeon would get paid $738.90, which is the fee before his or her office expenses are considered. This $738.90 needs to cover his or her office space, staffing, medical liability, and years of training to have the privilege of performing this life saving operation. Thus, the doctor actually gets paid 1.4% ($738.90/ $50,000) of what President Obama claimed he got paid. There are other fees for the hospital but these are not related to a doctor’s compensation. This clearly illustrates that doctors payment systems are confusing for patients and creates much anxiety when trying to decipher a bill in the mail. It is apparently even confusing to lawmakers and the President who are trying to modify reimbursement yet do not know how doctors get paid. This needs to be addressed so patients and lawmakers can understand where doctors are coming from. It also shows that doctors are not getting paid what some patients think as evidenced by some of the comments in the blog.

As Dr. Benjamin Carson recently stated, “it is very difficult to speak to a large group of people these days and not offend someone….the PC police are out in force at all times.” And if we continue to attack minor points and detract from the point of an article, we will never make progress. That being said, I have a tremendous respect for lawyers. Many close friends and relatives of mine practice law and they do noble things for their clients. Nevertheless, I was trying to illustrate how the pay structure for a doctor works and used a lawyer as a comparison as we are both hard working professionals. I could’ve used other professions that get paid hourly as examples as well because the payment system for doctors is still different. A good example of the difference in payment structure is as follows: if a patient has a colonoscopy and the “charge” is $2000, doctors do not get paid this. It is an inflated number as described above. A doctor gets paid whatever the Medicare fee schedule dictates (code 45378), which is the same for all doctors assuming they live in the same region. This payment is a small fraction (10-40% depending of insurance carriers) of what the initial charge may be, and again, this is before practice expenses. Further, if that doctor comes in the middle of the night to perform this procedure, he or she gets paid the same and he or she does not charge extra. Doctors do not collect whatever they want for clinic visits or procedures. In addition, if one procedure takes longer than average or is more complex, a doctor does not collect more for that procedure unlike other professions that are paid hourly. The fee is pre-determined by the Medicare fee schedule no matter how sick the patient is. This is clearly different among other professions like law. In addition, if there is a follow up call or letter after the procedure, this is all part of the one fee and no additional fees are billed. If that patient calls at 9pm that night or the patient arrives 30 minutes late to an appointment, there is not an increased charge. I am not stating the way lawyers get paid is flawed or wrong; I am simply stating it is very different and sometimes this contrast is not noticed. Do I speak with patients at 9pm and do I spend the extra 30 minutes helping patients get the quality care they deserve? Of course, I willingly do this because I went into medicine to help those in need and I get satisfaction from this. I do worry, however, that this may not continue to be the case for all doctors if reimbursement models are not modified and doctors’ fees are not corrected for inflation and practice expenses. They simply will not bring in enough revenue to cover their expenses. Again, doctors’ fees have been declining, are not secure (please read about the erratic nature of the SGR formula), and do not adjust for inflation.

In conclusion, the previous article was intended to show lawmakers what doctors go through before policy changes take effect that make it more difficult to provide quality advanced care. We are already seeing a trend towards concierge medicine, which likely will increase costs for patients. We as doctors have a calling to help human beings and we take this seriously. However, we feel that Capitol Hill needs doctors from the front lines to discuss our issues so that the best reform possible can be made. A lot of recent articles point to reimbursement to doctors as a reason for health care costs rising. Looking at it more carefully though, there are definitely other issues that could be addressed (and should be reserved in a separate blog), but it will take Congress to seek out doctors with experience on the front lines of care to help them arrive at a fair system that can benefit everyone. And that is my hope. That Capitol Hill realizes this and recruits a diverse group of practicing doctors (not lobbyists or lawmakers) who can shed insight into the current issues at hand.

-Matthew Moeller is a practicing Gastroenterologist. He can be reached on twitter (@DrMMoeller).

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