What's Your Doctor Worth?

American Thinker ^ | January 25, 2007 | Linda Halderman, MD

[neverdem]

How much money does your doctor earn?  If your doctor is a Surgeon practicing in rural central California, you're about to find out.

First, some background:  Perhaps your 51-year-old neighbor's screening mammogram this year showed a suspicious area.  She is called back by the Radiologist for more testing, including additional mammograms and an ultrasound.  She then receives a call from her Gynecologist explaining that the x-rays are "non-reassuring," and she'll be sent to a specialist in breast surgery.

That's where my office gets involved.  Five or ten faxed pages arrive on my assistant's desk.  She calls the Gynecologist's office to request additional material, including copies of the mammogram report, the patient's contact information and insurance data-if the patient is insured.

As it happens, like more than 60% of the women I care for, this patient is either uninsured or underinsured by Medi-Cal or BCEDP, the State of California's breast cancer detection program for low-income women.

The paperwork piles up.  Now my assistant must confirm eligibility in addition to scheduling the consultation, creating a chart and retrieving x-rays for me to evaluate.  Prior to the visit, I review the chart and create an electronic medical record.

Next, the visit.  Your neighbor arrives at my office.  I speak with her for about 15 minutes, learning her medical and surgical history, asking about symptoms and risk factors, and answering questions.

I examine her carefully, assessing not only for breast abnormalities, but also for swollen glands in eight regions of the body.  A heart and lung exam is done to identify problems that would make her a higher surgical risk, and the neurological, abdominal and musculoskeletal evaluations provide evidence for or against tumor spread.

After my patient is dressed, she asks me to bring her sister and husband in for the discussion of my recommendations.  This is often the most time-consuming part of the visit, requiring patience, repetition and reassurance for a frightened patient and her concerned family.

Although our first visit has ended, the work has not.  I fill out a form ordering testing to further characterize the abnormality seen on my patient's mammogram.  I'll pore over a list of codes required by Medi-Cal to identify the visit, choosing the most appropriate ones and hoping they don't merit automatic rejection of the bill (a frequent occurrence, prompting up to nine months of back-and-forth debate with Medi-Cal).  Because the necessary biopsy requires a Radiologist's assistance, I'll communicate with him as well as the Pathologist who examines the specimen provided.

The diagnosis is Breast Cancer, and it's my job to break the news.

Our second visit is very different.  Not only do we talk about her diagnosis, we review all of the options for treatment, alternatives and their possible outcomes.  There may be tears and anger, self-blame and fear, and the inevitable, impossible question: "Why?"

This visit is the most difficult one for my patient and her family.  I, too, find it the hardest part of being a Breast Cancer Surgeon.  Some wounds cannot be healed with sutures and sterile bandages.

Back to the question at hand: How much is your doctor paid?

What payment will be made for the initial consultation and exam?  What dollar amount is assigned to the time spent with my patient and her family, explaining and encouraging, counseling and comforting? 

Every doctor who practices independently must be not only a medical expert but also a good enough business owner to keep the doors open.  No amount of compassion, however critical to successful treatment, will pay the bills. 

Payment for a visit must cover the rent and utilities to keep the office open.  Office staff needs to be paid, their health and dental insurance premiums covered.  There are additional payments to be made for Worker's Compensation, malpractice and liability insurance.  Office supplies, medical supplies, biopsy equipment and disposable instruments are essential and expensive.  There are also laundry and cleaning expenses, postage and biohazardous waste service.  Your doctor must also pay the 24-hour answering service, the billing company, as well as the bookkeeper, accountant and attorneys.   And, like everyone else, your physician must pay Federal taxes, State and local taxes, payroll, income and unemployment/disability taxes.

Here are the actual Medi-Cal billing codes and payment schedule for central California breast cancer Surgeons in 2006:

For the initial consultation and exam of the lady with the abnormal mammogram:

CPT#99243 $59.50.

For the visit in which she is told she has Breast Cancer and is prepared for surgery:

CPT#99213-57 $24.00.

This is what your doctor is paid.  Now ask yourself what she is worth.

Dr. Halderman is a Board-Certified General Surgeon practicing in rural south Fresno County, California.

[Fairview]

The point I am trying to make is that the average person thinks that the average doctor is "rich," and has no idea that (a) most doctors these days are comfortable but far from being rich, and some have real financial problems, (b) the headaches and risks of practicing medicine in the present economic climate is making a lot of them consider leaving the practice of medicine altogether, and (c) their compassion is not in short supply, especially considering that all work done for elderly and Medicaid patients is charity care.

[DB]

It is a community hospital that gets public funds. I don't know the details of how that works though.

I spent 20+ hours with her in the room. That $500k bill would have more than paid for every piece of equipment in the room. It was mostly old equipment and they've recouped the cost many times over.

[Doghouse Riley]

This article is a well-written, eloquent plea for more of my tax money.

Forget it.

Unless we get a socialist program in which MD's are required to participate or face prosecution, Dr. Halderman is welcome to decline these patients.

As long as taxpayer money is funding Care/Caid I want the payments to providers set aggressively low.

[Kozak]

Clicking on the link shows that the good doctor is a California plastic surgeon: "offering Medical Spa Services, we provide a place to improve and maintain your appearance in a safe, professional environment."I doubt that we need to take up a collection.

And as a plastic surgeon she doesn't HAVE to work in a situation where she accepts Medicare or Medicaid. She can set it up to demand cash up front. Of course that means no mastectomy or reconstructive surgery for the Medicare or Medicaid patients. Does that situation make you happy?

[DB]

I should add, the truth is, she (and the insurance company) are paying for all the others who didn't pay - particularly the illegals. It isn't that her specific care cost $500k, it is her care in addition to the many before her that didn't pay their way.

That is wrong.

If the voters demand that hospitals take care of illegals and dead beats then it is the voters who should pay the cost directly. Not the next person that comes through the hospital door sick and who happens to have insurance or can otherwise pay.

And just perhaps if they started bearing the burden of their vote they'd vote differently.

[Doghouse Riley]

What we really need to move to is a two tier system where those who are getting their care on the taxpayers dime can get it in a clinic situation -- salaried MD's who have part/all of their educational expenses subsidized and have no malpractice worries.

Raising Care/Caid rates to the point where they are "profitable" for private MD's in boutique practices is not the solution, unless you want to see your taxes skyrocket.

[durasell]

Boutique or concierge practices usually don't accept insurance.

[Conservativegreatgrandma]

You're starting to catch on. People go to doctors far too much. They're just as capable of making matters worse as to making matters better. Doctors are very poor at treating chronic disease. They only treat symptoms, many times creating new symptoms in the process.

I've found a favorite new website: www.curezone.com

[Jim Noble]

If the voters demand that hospitals take care of illegals and dead beats then it is the voters who should pay the cost directly.

But they don't.

So, should the hospital, which maintains and provides for an ICU (and not just an ICU - an operating room, an emergency room, beds, a kitchen, heat, air conditioning, a staff of hundreds (at least) ready to care for you at the drop of a hat - should that hospital, which in all probability recieves ZERO of its operating overhead ($100 million/year, probably) from the taxpayers - should it close, or should it send bills?

Which is it?

[from occupied ga]

While I'm sympathetic to the writer of this article, someone is making money. A lot of money.

More like a lot of people are making a little money each. Take surgical billing at a large hospital. Lets start with 20 operations of $5000 professional fees each. First only 40% of these are ever collected because of insurance underpayment and the fact that a lot of people simply don't pay. so we're down to $40,000. The dean of the medical school now takes 16% off the top to support the medical school so now we're down to $33,600. The hospital charges the surgeon 60% of the collected bill for overhead - support staff OR supplies salaries for anesthesiologists, OR techs, etc. so thats another $24,000. If you subtract this from the 33,600 that's left after the med school gets theirs, then the surgeon gets $9600 for 20 operations or about $480 each. Now the surgeon has to have initial clinic, pre-op clinic, the operation itself, and followup care. Say 2 hours before the operation, 3 hours for the operation, and about 3 hours after the operation for followup the hourly rate that the surgeon gets is about $60/hour. Not a whole lot for the level of training and commitment that the job entails.

The biggest cost is the cost of treating non-payers, so when you see the ER crowded with people who only speak spanish, you can bask in the warm glow of knowing that your money that you're paying for your health care is actually paying for them too. (Thank you Jorje Bush for making the USA the welfare choice for Central America)

[CharacterCounts]

She did.

No. She did not!

She gave you an isolated example of one case.

A relevant answer would have been the income she reported on her federal tax return.

[DB]

"But they don't."

And there lies the problem.

It isn't a choice of "which is it". The whole thing is built on a series of bad choices - all stemming from government mandates/regulation. The only solution with any hope of actually making things better is getting the government out of health care. Not more of the same.

As it always is, the solution to the problems socialism causes is always more socialism... It never occurs to the bureaucrats that their "solution" is the actual source of the problem they're trying to fix.

[from occupied ga]

A lot of money.

One thing I forgot which is a large part of the hospital 60% overhead is that the hospital covers malpractice out of this overhead too.

[durasell]

Wow, so they'd actually make more working within a framework of socialized medicine! Amazing that the AMA isn't storming the steps of the Capitol demanding gubmint work.

[DB]

Wrong.

She took the example given knowing she wasn't going to be paid what her time was worth. In other words it was basically charity. She would have very likely made more money not accepting such patients. So who is going to care for these people if no one is willing to see them?

Most businesses can't afford to run their business as a part time charity. Nor should they be expected to.

[DB]

Yes - and in that case the people making "a lot of money" are the parasite lawyers...

I don't want to pay to make lawyers rich because I'm sick.

[Jim Noble]

The biggest cost is the cost of treating non-payers

The biggest cost is overhead.

The difference between the facilities and equipment that a hospital had to maintain in 1970 and now is staggering.

DB is complaining that her niece was in a modern ICU with pneumonia for two weeks (and presumably lived), and that it cost $500K.

The cost of having that ICU available 24/7/365, so that her niece, and everybody else's relatives, can drop in at 3:30AM critically ill and survive, is enormous.

And DB doesn't think her niece should have to pay for that cost (as opposed to her actual resource use).

But DB has not answered the question of who that hospital SHOULD send the bill to for weekly maintenance on the ventilators, or for the on-call respiratory therapy staff, or all the other stuff required to have that unit ready for her niece to drop in with pneumonia.

THAT'S the cost problem. It costs tens of millions of dollars to staff, equip, and maintain ICUs and ERs in a ready condition, and no one wants to pay.

[mo]

Follow the money...dollars are the corpuscles of the truth here....its is far, far cheaper for the insurance company and the payer of last resort, the Feds(you and me), when a patient succumbs to an intracerebral hemmorrhage than to go through apprpopriate, highly skilled and technical intervention resulting in several weeks of hospitalization and rehabilitation.

[durasell]

In my experience, doctors who are struggling are struggling because they're either in a market with little or no money or happen to be hacks.

You can still make a darned good living as a doctor.