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Devaluing Doctors -- and Care

By Marshall Ackerman
Thursday, August 20, 2009

Physicians have been cast as the villains in the drama that our national health-care debate has become. We stand accused of raising charges to private insurers to compensate for low Medicare and Medicaid reimbursements as well as care of the uninsured or illegal immigrants; doing more to get paid more; seeing patients more often than necessary to increase revenue; and providing inefficient and ineffective care to patients in the hospital. Our motives are impugned. The care we render is being disparaged and our professionalism disregarded -- yet somehow it is assumed that doctors are merely passive pawns to be moved around the chessboard of health care.

Where are the investigative journalists? How many physicians who are not radiologists own their own MRI machine, CT scanner, PET scanner or other sophisticated diagnostic equipment to which they refer their patients? Why would President Obama blast pediatricians for doing tonsillectomies for profit, when any intelligent person knows that pediatricians do not do surgery? They care for sick children and refer them to ear, nose and throat specialists when surgery is needed. Why does no one seem to be aware that surgeons have functioned under a "global reimbursement" system for more than 35 years? Surgeons are paid a set fee for the care rendered for surgery or fracture care for a fixed period (frequently 90 days) regardless of how often they see a patient or how long the patient remains in the hospital.

For that matter, why would intelligent physicians fill their schedules with unnecessary return visits for Medicare/Medicaid patients, who are the lowest payers in the mix, limiting the number of new patients they could see? And how is it that so many physicians "pass along" the losses of caring for the uninsured or Medicare/Medicaid patients when in fact doctors labor under contracts with big insurers that are basically take-it-or-leave-it with payment rates not much higher than Medicare, which has become the new standard?

I have been a practicing orthopedic surgeon for 40 years. I have observed profound changes in my profession since the advent of Medicare, changes that have affected patients' access to care. As reimbursements plummeted, internists abandoned hospital care to the new specialty of hospitalists, created boutique practices and stopped participating with health insurance companies. Physicians in all specialties have been retiring at earlier ages than ever before. In my own office, our staff has doubled over the past 40 years to enable us to handle the growing stream of government and insurer mandates. Our reimbursements continue to drop -- with no ability to pass on these costs. We are not the Mayo Clinic. There is no foundation to provide computers and electronic medical records or research grants to supplement salaries. Everything we do must come out of the reimbursement we receive for the care we provide to each patient.

Total joint replacement surgery for an arthritic hip and knee is a prime example of the difficulties physicians face and of the implications of health-care reform as envisaged by Congress and academic "experts." In 1971 I was paid $1,000 for a total hip replacement. Today, I would be paid approximately $1,600 for the same service. There is no multiplier -- a surgeon can only do one patient at a time. We continue in our practice for the immense satisfaction we receive from knowing that this surgery does more to restore a high quality of life to patients than any other surgery, and for the gratitude patients show. We implant devices because we believe, based on medical literature, that they are the best choices for patients. The overwhelming majority of surgeons have not received fees from implant manufacturers -- many times lowering the profitability of our hospitals.

Consider the implications when a global fee will be paid to the hospital: Then hospital and physician incentives will be aligned, and patients will bear the cost of the search for ever-cheaper implants and techniques, such as a return to cemented total hips. Forget metal-on-metal bearings, resurfacing, rotating platforms, high-flex knees, navigation systems or bilateral replacements. And if our hospitals are financially penalized for occurrences such as infection and deep-vein thrombosis after surgery, who will operate on the obese, the hypertensive or the diabetics among us? Experience with government funding reveals a never-ending spiral of decreased reimbursements in the name of restraining costs. In the end, this will come out of the care we all receive.

At your next visit to your specialist, take a tip from the drug company ads and "ask your doctor": Does he or she plan to retire early if reform legislation passes close to its present form? Does he or she plan to continue to participate with Medicare/Medicaid or participate with insurers that will not reimburse adequately? How does your doctor think health-care reform will affect the care you receive in his or her specialty? Access to a waiting list is not access to health care. Let's stop pointing fingers and start considering the real flaws and strengths of our system and how to improve it.

The writer, an orthopedic surgeon, has worked in private practice in the Washington metro area since 1969.

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