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David Fisher, MD, MPH: Does Your Doctor See Dollar Signs in Your Kid's Throat?

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Thursday, July 23, 2009

Does Your Doctor See Dollar Signs in Your Kid's Throat?

If you watched President Obama's press conference Wednesday night, you may have come away with the impression that doctors are often thinking about how much money they can earn from your illness as they make decisions about your health care. Here are his comments from the transcript at CBS News:

"Right now doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. So if they're looking -- and you come in and you've got a bad sore throat, or your child has a bad sore throat or has repeated sore throats, the doctor may look at the reimbursement system and say to himself, you know what, I make a lot more money if I take this kid's tonsils out....Now that may be the right thing to do, but I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change -- maybe they have allergies, maybe they have something else that would make a difference."

In my experience, this dynamic rarely happens in primary care. Sure, if you are seeing a specialist whose earnings are based on performing one or two highly specialized procedures, he or she is more likely to recommend that you have that procedure. In the vast majority of cases, however, doctors are not calculating what decision is going to earn them the most money. For one thing, repayment schedules are so complicated these days, that it is difficult for doctors and medical office managers to know if and when they will be reimbursed at all for a day's work. Many insurance companies' payment schedules, including Medicare and Medicaid, are designed to pay only a percentage of what the doctor actually bills, so even if a doctor wanted to figure out how much he or she would make based on a specific decision, it would be nearly impossible to do so in today's system. (If you've ever seen a hospital bill that your insurance company paid, and you were shocked at the numbers, you should know that the hospital and doctor probably only received a percentage of what was actually billed, and they were forced to mark up the fees in the hopes that what they are actually paid would at least cover their costs for the hospitalization or procedure).

For President Obama to imply that doctors are performing unnecessary surgeries on children for their own financial gain is an insult to the medical profession. The very procedure that he referenced disproves his own theory. Tonsillectomies have dramatically decreased over the past 2 decades because doctors recognized that removing a child's tonsils did not prevent infections like it was once thought. Therefore, ENT specialists and pediatricians stopped recommending tonsillectomy as often because it became clear that the risk of the surgery, though small, outweighed the potential benefit in most cases. Financial factors played no role in this trend. Practice guidelines published by doctor's associations are always rooted in data about patient outcomes. If a procedure or treatment produces good outcomes, it is recommended. If it does little to help patients or is too risky, it is not recommended. The doctors I know and work with attempt to follow these guidelines as closely as possible, whether or not they will benefit financially. Practicing medicine is a lot different from practicing law, where lawyers can bill an hourly rate for just about everything they do. I hope President Obama is not relying on his background in law as he conjectures about what doctors think when they look in your throat. Your doctor is almost certainly thinking about what decision will help you the most, and not what will help his or her pocketbook.

1 comment:

Anonymous said...

This was an astonishing thing for the President to say. Interestingly, support for his healthcare reform proposals has taken a nosedive since he opined.

Reminds me of last year's Republican opposition to the Medicare Improvements for Patients and Providers Act that was drafted in part to stop the proposed physician pay cut for doctors who take Medicare. President Bush vetoed the bill and his veto was overridden by Congress. In the media, the GOP was painted as being anti-doctor and pro-health insurance company as a result.

I'm not sure why there seems to be a chapter in the political playbook that says one can further one's agenda by attacking physicians. The evidence suggests that this is the fast track to seeing one's agenda go up in flames.