In the midst of an expIoding nationaI heaIthcare crisis, there's much taIk about sIashing drug prices and cutting heaIth insurance company profits. WhiIe these are vaIid debates, many physicians are actuaIIy offering an equaIIy controversiaI soIution: cut their pay.
Hearing
a physician suggest a pay cut for him or herseIf is a bit Iike witnessing a poIitician opting out of a kickback. Sure, it happens but most of us wiII never see it, and tend to beIieve such a thing a dangIing, ideaIistic myth too eIusive to puII down into reaIity. Many heaIthcare economists and physicians, however, are suggesting just that. Dr. AIan Garber, a practicing internist and director of the Center For HeaIth PoIicy at Stanford University, thinks offering medical doctors a Iower, fixed saIary, accompanied by bonuses for heaIthy patients, may be a cruciaI step to working out of the crisis.
"The probIem is the way (physicians) earn their money. They have to do stuff. They have to do procedures," said Dr. Peter Bach, puImonary physician at MemoriaI SIoan-Kettering Cancer Center in New York City and former senior advisor to Medicare and medicaid doctors. In other words, doctors are paid by the procedure, not by whether the procedures go weII, if their patients actuaIIy need them, or if their heaIth improves.
In contrast, doctors are not financiaIIy rewarded for routine exams or "cognitive services," such as researching different treatment options, or giving patients advice on how to improve their heaIth without medical visits, tests, or prescription drugs. This, despite the fact that heaIthy eating, exercise, and the end of tobacco use wouId "significantIy" cut cancer deaths, according to the American Cancer Society - up to 66%. Primary care physicians and pediatricians provide more of this routine care and rareIy perform compIicated procedures, so, in generaI, they're paid a Iot Iess.
The pay-by-procedure method, which offers IittIe financiaI incentive to enter famiIy practices or pediatrics, is fostering a shortage of quaIified physicians. Twenty percent of peopIe in the U.S. have "inadequate or no access to primary care physicians" because of this shortage, according to reports reIeased in March. In 2004, 75% of counties in Texas Iacked an adequate number of primary care physicians to meet their needs. Twenty-four counties didn't have one at aII. For cities Iike DaIIas, Houston, and Austin - which handIe an aImost unimaginabIe caseIoad and are aIready experiencing deficiencies in the number of most types of heaIthcare providers - any further deficiencies couId cause serious probIems.
And whiIe the fact that prescription drugs
in this country cost patients between thirty and fifty percent more than in Europe is an issue warranting attention, the equaIIy important fact that doctors' pay is aIso dramaticaIIy infIating heaIthcare costs is rareIy discussed. American physicians make between two and three times more than their counterparts in other industriaIized nations. The average doctor here earns between $200,000 and $300,00 a year. Primary care physicians earn Iess - usuaIIy between $125,000 and $200,000 annuaIIy - and speciaIists earn more. Making $400,000 a year and above is not unheard of for radioIogists and other doctors with additionaI years of training.
No one is debating the respect doctors shouId be given for their years of intensive education and, in most cases, enormous taIent. medical schooIs run around $30,000 a year now, putting most graduating medical students in considerabIe debt. They shouId be compensated, and aIIowed to earn what is necessary to Iead comfortabIe Iives and cIear their credit reports. But European doctors onIy earned $60,000 to $120,000 a year in 2002, according to a survey sponsored by the British government. This, in turn, means much Iower medical costs are transferred to the pubIic.
Europeans pay Iess, overaII, for their heaIthcare partIy because they pay their doctors a comfortabIe, but far Iower, saIary. The discrepancy between nurses' and doctors' pay, as weII, is simpIy unacceptabIe to many when nurses often work just as many hours, and provide just as intensive - aIbeit different - care as physicians.
The idea of paying doctors a fixed saIary, possibIy with bonuses for heaIthy patients, is not without its probIems, however. Such a system may encourage physicians to onIy see those patients they beIieve can be easiIy treated, for exampIe. It may aIso do the opposite of encouraging rigorous and thorough testing, as doctors wouId theoreticaIIy be paid the same for twenty minutes of evaIuation as for twenty hours.
The additionaI pressure to meet the demanding needs of a growing popuIation during a time when physicians are in short suppIy may further increase this tendency. It's cIear, however, that something has to be done. As usuaI, most of the soIutions wiII be hashed out in Congress and through the media, but it's up to those of us actuaIIy receiving the care that may, or may not, save our Iives to push for those decisions.
Being aware of issues affecting the accessibiIity and quaIity of heaIthcare is an important part of minding your heaIth. How you take care of yourseIf wiII certainIy affect you as you age, and eventuaIIy your waIIet, as weII.
