Conspicuous on the front page of last Tuesday’s Wall Street Journal was this headline: “Taxpayers Foot Big Bills from Handful of Doctors.” It is a two-page story about a clinician whose practice drew attention from the WSJ research team that combed through the recently released Medicare Utilization and Payment database released in April. They wrote:
"Ronald S. Weaver isn’t a cardiologist. Yet 98% of the $2.3 million that the Los Angeles doctor’s practice received from Medicare in 2012 was for a cardiac procedure, according to recently released government data…The government data show that out of the thousands of cardiology providers who treated Medicare patients in 2012, just 239 billed for the procedure, and they used it on fewer than 5% of their patients. The 141 cardiologists at the Cleveland Clinic, renowned for its heart care, performed it on only 6 patients last year. Dr. Weaver’s clinic administered it to 99.5% of his Medicare patients…"
Lets face it: curiosity about what other people earn is a national pastime. Pro golfers qualify for their tournaments based on their publicly accessible official winnings. NFL agents bargain for their clients based on position-specific compensation comparables. We are frequently reminded that members of Congress “officially” earn $174,000 plus attractive perks, and of late, executive compensation for most of America’s public companies has become a major focus for Board Compensation Committee’s who are being pushed by shareholders to reign in their generous comp packages. So it’s understandable that physicians bristle at stories like this one. We would as well if in their shoes.
Here’s why the story is particularly challenging for the medical profession:
1-Physician income is high relative to what most American’s earn. Though wide-ranging across the various specialties in medical practice, the ratio of physician income to the median income in the U.S. ($51,324) is from a low of 3.6:1 for family practice to 13.9:1 for the highest earning clinicians in radiology, orthopedics and others (and that does not include their income from ownership in surgery centers, testing facilities and other services). Physicians think they deserve to be paid more than any other professions, reasoning theirs is a higher calling, their debt higher (averaging $170,000 for the 86% that borrow for medical school) and their training and expertise more valuable to society than others. Stories like this draw attention to how much physicians “might” earn and lend to suspicions that belly-aching by some in their ranks claiming they earn too little is more about greed than the greater good. Income potential is important to everyone: physicians want to earn as much as they can, and keep score against their peers and other high-earning professions. Many feel underpaid; some indeed are. But relative to what’s made in the vast majority of households, they are well paid.
2- Physicians practice in a high profile industry and the spotlight is getting brighter. It’s 17% of our GDP, 28% of the federal budget, 34% of a state’s budget, and 9% of household discretionary spending. It impacts every one every day—in the costs of what we buy, in the ways our wages are set and in the intense political debate about health reforms to keep Medicare solvent, increase access to affordable insurance and holding down costs. The release of the Medicare Utilization and Payment Database represents another layer of transparency about physician behavior that’s accelerating at warp speed. Aptly, the Wall Street Journal’s story about Dr. Weaver’s practice is part of its series “Secrets of the System” dating back 3 years. USA Today calls its current series “Medication Generation” and Elizabeth Rosenthal’s New York Times series “Healthcare’s Road to Ruin” are prominent in top tier coverage, not to mention the blogosphere and social media fascination with healthcare’s complexities, conflicts, deals and personalities. What physicians do and how much they earn is part of the new normal in healthcare wherein transparency is an end in itself.
3-Physicians and other stakeholders in the system have inadequately addressed the issue of medical necessity in the profession. Medical necessity is a tricky issue. It presumes a binary assessment about a possible treatment: either it works or not. But it’s not that simple: the signs, symptoms, risk factors and co-morbidities that factor into a diagnosis or treatment recommendation are complex. Evidence is scant for some treatments. And the data upon which the determination of “what works best and how much” is rarely accessible to a practicing physician for two reasons: 1-most physicians don’t have hard data about their practice patterns, outcomes and alignment with evidence-based practices due to the costs of these systems and 2-they believe outsiders—especially health insurers-- have no legitimate standing in the important discussion of medical necessity. If adherence to evidence-based healthcare was the focal point for the profession, disclosures about each physician’s adherence to evidence-based practices, outcomes, and patient experiences would be readily accessible today. Disciplinary actions against physicians who abuse would be higher and hospital privileges yanked faster. And for sure, insurers would be quicker to drop them. But that’s not the case. If unnecessary tests, surgery and medications represent 30% of unnecessary health spending in the U.S. per Dartmouth, attention to a remedy by the profession and by the rest of the stakeholders is not readily evident: for sure, it needs to involve liability reform, but much more. For many clinicians, fear of being sued is merely an excuse to practice medicine as they choose with limited accountability to their patients, payers and peers for medically necessary care. It’s an issue the profession must face head-on.
The bottom line: The presumption that a physician might practice with unfettered autonomy and protected privacy is a legacy of a by-gone era. Modern medical professionals understand the profession’s changing. They acknowledge they practice in the spotlight and know their reputation is increasingly dependent on “hard data” about their clinical practice patterns and outcomes preferred by health insurers, employers and individuals.
Schools of Medicine face a daunting task of implementing reforms that equip their grads to practice in the new normal. Teaching hospitals face incredible responsibility to immerse residents in clinical practice that’s consistent with technology-enabled, team-based care management. Medical groups and health systems face responsibility and risk to measure the performance of their affiliated physicians and weed out bad actors prone to unnecessary care.
Most physicians love the practice of medicine. They resent intrusion by outsiders of any stripe—media, insurers, administrators, and even their peers. Physicians are understandably frustrated by stories that paint the profession unfavorably. Like any profession, there are bad apples. But medicine, whether they like it or not, is in a uniquely sensitive spotlight that’s likely to grow brighter.
Sources: John Carreyrou, Christopher Stewart, Rob Barry “Taxpayers Foot Big Bills from handful of Doctors” Wall Street Journal June 10, 2014; Modern Healthcare’s 2013 Physician Compensation Survey published July 15, 2013 based on synthesis from 15 physician recruitment/compensation consultants; CMS.gov Medicare Utilization and Payment Data released April 9, 2014;; Lawrence, David Building a Better Delivery System: A New Engineering/Health Care Partnership – Bridging the Quality Chasm. Washington, DC: 2005 National Academy of Sciences; Elliott S. Fisher "The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care". Annals of Internal Medicine February 2003: 138; Elliott S. Fisher et al "The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care". Annals of Internal Medicine February 2003; Public Citizen: “State Medical Boards Disciplinary Actions” March 15, 2011; American Board of Internal Medicine Foundation “Choosing Wisely” Campaign 2012