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).

Follow caduceusblog on twitter (@caduceusblogger)

Related Posts: Open Letter to Washington from a Physician on the Front Lines;   Should  a Medical College Dean Take Money From Pharma (while telling their students not to)?;     Doctors Are Being Gagged by Gas Drillers;     Healthcare Armageddon 6: Medicare and Generation X.

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  • Edward Volpintesta MD

    March
    30, 2013

    Caduceuslog.com

    I
    appreciate the comments made by Matthew Moeller MD posted on the March 28
    Caduceus.blog. His willingness to speak openly and freely is admirable and I
    wish more physicians could muster the courage to do the same. For many if not
    most physicians suffer silently and to borrow a famous phrase of Thoreau’s lead
    lives of quiet desperation.

    My
    response to his blog however is directed not to the time and the financial
    burden but to the medical curriculum itself.

    I
    have been practicing primary care for almost 40 years. And as I look back on my
    years of education I realize how much of it was either redundant or
    inappropriate.

    For
    example, as I look back on courses like organic chemistry, physics,
    biochemistry, biology of vertebrates, and physical chemistry which I labored
    thorough because I was told medical schools favored students who took those
    subjects—and the time and worry I spent on them I am overcome with a sense of
    regret. For the time invested in them has contributed very little if anything
    to my capability as a general practitioner. Ironically a great deal of time is
    also spent on the so-called basic sciences in medical school as well.

    The
    basic sciences have their place in medical education of course. But, studying
    them with the intellectual exactness that is more appropriate for a career in
    medical research doesn’t makes sense.
    Some of these subjects I suppose are intended to weed out those students
    who do not have a superior aptitude for science. Unfortunately many students
    who could have made good general practitioners were either turned off from a
    career in medicine or refused admission to medical school because they were
    daunted by organic chemistry or biochemistry.

    My
    point is that perhaps the medical education experience doesn’t have to be so
    long and arduous. Certainly surgeons need their operating room experience to
    develop their skills but even their pre-residency education could be modified
    to be more practical. This would save time, money, and energy for those
    pursuing medical careers.

    Many
    believe that the Flexner Report of 1910 which set new standards for medical
    school is greatly responsible. Abraham Flexner undertook a study of American
    medical schools, identified their deficiencies and with the power of the
    Carnegie Institute and the Rockefeller Foundation supporting him set in place a
    new set of standards. They were inspired by the German medical schools whose
    main focus was on medical research. That focus has remained in place and has
    been the foundation of American medicine ever since.

    Clearly
    the medical schools of the time needed the improvements in standards that
    Flexner promulgated and no one would doubt the benefits that have accrued
    because of medical research.

    But
    the overriding attention to research encouraged the training of specialists and
    did all but ignore the training of general practitioners.

    This
    unintended effect of Flexner’s report is responsible to a great extent for the
    primary care shortage that is constantly reported in the media. Perhaps if
    Flexner were a physician his approach might have been different. He was an
    educator not a doctor.

    One
    of his contemporaries, Sir William Osler MD a celebrated physician, teacher,
    and author of a highly regarded medical textbook disagreed with Flexner’s
    ideas. He preferred that medical research be done in institutes and not in
    medical schools attached to teaching hospitals. He was also against full-time
    teachers in the hospitals because he thought that not being directly involved
    in private practice in the community did not give them the exposure to the
    practical needs and problems of patients outside of the hospital environment.

    Be
    this as it may, some leaders in medicine are seriously taking a second look at
    the changes that followed in the wake of Flexner’s report with plans to correct
    any unintended consequences.

    If
    they do a good job future physicians may be spared some of the stresses and
    adversities that Dr. Moellers described.

    Edward
    Volpintesta MD

  • I understand exactly what Dr. Moeller explains in both of his letters. I understand that when my orthopedic surgeon did a wonderful job fixing my torn rotator cuff, he did NOT get paid the $20,000 that was the total cost for the procedure. I’d be surprised if he made more than $1500. It’s easy to see where the rest of it goes…. charges for the use of the hospital “room” which was an outpatient pre-surgery room, the use of the operating room, the use of the recovery room, the medicines for my aenesthesia, antibiotics, and pain control, the charge for the aenesthesiologist, the charge for the pre surgery nurses, the operating room nurses, the post care nurses, the hospital office and staff charges for paperwork, and a lot of other things that I didn’t understand. Although I do think my surgeon makes good money, he should. In addition to all of his training and expertise, he spent many years as a flight surgeon in the Air Force, where I doubt his pay was nearly as good. I do understand a little about medical billing, just from reading articles, and from asking questions about my bill. It may on paper that the charges for a yearly physical are close to $1,000, but I know that most of that goes to all kinds of stuff besides payment to my wonderful doctor. It’s no wonder that they cram them into seeing between 2 and 4 patients an hour: fifteen minutes for an office visit, and thirty for a physical. And I can imagine his head spinning after an eight hour day of seeing that many people. As a former high school teacher, I know how people can misunderstand a job. Doctors are thought of as “making the big bucks,” when people have no clue as to the cost of their education, continuing education, fees for liability insurance, professional organizations, and the loss of those earning years between the ages of 22 and 30. With teachers, what we constantly hear is, “Oh, you have the best job. Don’t complain about your low pay! You get off of work every day at 2:30 or 3:00, and you get two weeks off at Christmas, a week in the spring and three months in the summer! Give me a break!” What they don’t know is that many teachers either come to school in the wee hours of the morning, or stay late in the evenings. Most days I did not leave until 6.p.m. and at least two nights a week, I’d have to stay until 7 or 8. My friends would ask me, “Why? Why do you have to stay so late? What do you do?” I would explain that our second work day begins when the kids walk out the door. That is when we plan for the next day or week, grade papers, get materials ready for the next day, tutor kids, attend meetings and workshops, serve on several different required committees (benevolence, site based management, school beautification, at risk students, school dances, festivals, etc), attend after school events such as Parent Teacher meetings, open houses, games, plays, band or choir performances, award ceremonies, etc. Many teachers work with extra curricular groups before and after school, such as Key Club, National Honor Society, Student Council, International Club, Science and Math club, etc. Some teach school all day and then coach after school. In addition we have to keep up our continuing education hours and often have coursework and tests to take, or presentations to make. We have to document all of the things that we do in our classrooms to line up with our school improvement plan, and we have to also fill in reports and forms about what we do to streamline and modify lesson plans for studens with individual education plans… kids with learning problems, and how we comply with federal laws regarding the education of these kids. Along with continuing education, we also keep up with all of the new technology making itself into the classroom. We might train on a grading and reporting system that we use for two years, only to have the district throw it out and purchase a complete new system to learn. And, we take all kinds of calls from parents before, during (on our “planning” period) and after school. Some of these calls can last as long as a parent wants to talk… or complain. Occasionally, instead of calls, we have individual parent conferences, and these, too can take a lot of time. We talk for an hour with a parent about how to address the kid’s unwillingness to pick up a book to study, we offer solutions, we offer tutoring hours, we come up with a plan, only to have the parent and the student to drop the plan and then complain about the low grade again the next six weeks. Teaching can be extremely stressful, and the only reason that most of us stay in it is because we love it. We are often, especially in middle or high school, greeted by students who disrespect us first, and we have to earn their respect and their attention. Christmas break is usually a mad scramble to finally get everything ready for our own families in a very short amount of time. December and May are the craziest months in the year for teachers: so many programs and activities at school, all while nearing the end of the semester and the final grades. And of course, increasingly, teachers’ salaries and even jobs are tied to test performances by their students… and some of those students don’t care about their grades. When you look at our summer breaks, they are often bogged down by attending a college class or two, or working with planning committees for the next school year. We may get a couple of months off in the summer (it is rarely three months anymore) but after the maddening school year, every teacher needs a long breather. People don’t understand what we do. And people do not understand how doctors are paid, or exactly what they do, either. They, too, also have a lot of extra things beyond just their regular jobs, such as continuing education, re-certification, new technology to learn, and committe or professional organization meetings and duties. Doctors have to deal with patients who don’t follow instructions, and turn up even sicker. A lot of their patients and their families are sometimes very demanding and difficult. There are so many similarities between doctors and teachers. I am extremely grateful for the good doctors that I’ve had over the years, and I hope that every one of them eventually enjoys a great lifestyle in compensation for the long years of training and the excellent care they give, and for the hours they put in every week. As for Dr. Moeller and his salary, I wish he would investigate relocation to the Carolinas, or to Texas, or other states where I believe the doctor compensation is better than what he is currently earning. I think that some medical communities are much better than others in terms of work-life load and pay. The Carolinas Medical Center located all over North and South Carolina is a fine institution with great places to work and live. The climate and beauty of the Carolinas make the area a wonderful place to live. The best doctors I’ve ever had have all been under the CMC group. They all seem happy with their work, and so do all the staff. Their blend of friendly professionalism and excellence really transcends to patients in confidence and ease of visits. I’ve seen internists, G.I. doctors, orthopedic doctors, aenesthesiologists, general surgeons, allergists, immunologists,dermatologists, physical therapists, and physician assistants, and in eight years, I have yet to meet a cranky tech, nurse, office staff person, or doctor. Pretty good performance, I’d say! I hope they do all earn a great salary. It’s annoying to hear people run the medical profession and their salaries down, because they all work very hard, and have come a long way to get where they are.

  • North Carolina PA, MPH

    I agree that Dr. Moeller, and the entire medical profession, have made tremendous personal and financial sacrifices to pursue the study of medicine and then to practice medicine.

    Perhaps as a society, however, we should be looking at medical education from a different angle. This is the angle: How can the US best train the optimal mix of health care providers to meet the medical needs of our country?

    Perhaps the US medical education system is creating too many Mercedes-Benz and Lamborghini’s when most consumers really just need a Ford Focus or Honda Accord.

  • mtbwalt

    Dr. Moeller,

    The problem is that your reasoned plea falls on deaf ears, and the battle is already lost.

    What matters to politicians are revenues, campaign contributions, wedge issues, corporate cronyism, and personal power. Power attracts the corruptible, and Washington DC is rife with it. Try meeting with a Senator without a $10,000 check in your hand.

    In the setting of health “reform,” the political goals are to control (and divert portions of) the river of money paying for health care; to reduce the amount being paid into health care; and to further consolidate political power and authority. Quality patient care isn’t last on the list; its not even on the list. And being humane to doctors… hahahaha

    Physicians are standing next to big pharma, big hospitals, device manufacturers, etc. Somebody has to be the fall guy, and those unified, organized, and extremely well-funded other branches of medicine are not going to be it. Docs salary may only make up 15% of the health care dollar, but docs are fragmented and are being encouraged to infight (specialist vs generalist, etc) in order to prevent any political power. Need an example? ACOs. Designed to take from specialists, give a little to generalists, and the gov’t keeps the rest. What a great way to put primary care and specialists at each others throats! One feels threatened, the other unappreciated.

    Your plea is heartfelt. But the political class – the most cynical, corrupt, arrogant, entitled group imaginable – couldn’t care less as long as they personally get great care (which they ensure). This is a group that that appointed Kathleen Sebelius, the head lobbyist of the Kansas Trial Lawyer Association, as the Secretary of Health and Human Services in charge of all of medicine! Talk about putting the wolf in charge of the sheep pen. Didn’t you get the memo, doctors are performing unnecessary tonsillectomies all the time and amputating people’s feet just to make $50,000 a pop (actual medicare reimbursement for amputation: $541). The President of the United States said so.

    They do not share your sincerity or care about anyone’s story unless they can use it to gain votes, money, power, and influence. You honor them far too much by writing a letter the tone of which assumes that they are caring human beings.

  • Kevin Williams

    Dr. Moeller, do you realize that in 81% of your sentences, you manage to compliment yourself as a saintly, caring, and certainly not whining about more money for yourself, type doctor.