Wednesday, September 5, 2012

What's wrong with the medical system of America
















In general there are a couple things that people can't live without. Shelter, food, clothing, and access to healthcare are the basic necessities that I think most people would agree on. Most of these don't require training to obtain, except of course for proper healthcare.  Ask most doctors what they've been through to achieve their degree, many will say they've sacrificed quality time with their families, happiness, personal relationships, and health all in the name of helping other people.

Doctors as a group represent of body of people that are generally altruistic, selfless, and by virtue of their profession they must have a high ethical backbone. Obviously this is not true of all doctors, and if anything doctors are not put on the same pedestal they once were. Doctor's almost had a saint-like persona several decades ago, and perhaps the increase in access to information has led to people questioning them, which to some extent is a great thing, on the other hand I think this change has also pushed many people to believe that doctors aren't good people, in fact a sort of demonetization of doctors has started to occur in the past 30 years or so. Doctors have been accused of being greedy, corrupt, and people blindly believe this, without asking a fundamental question, why has this behavior started to rear its ugly head? Why in the last 30 years have doctors been documented being crooked perhaps more so than in the past? The answer lies in the flaws, and changes in the American health system as we know it, and as you read, I think these points will clarify themselves. You can almost think of this as an economical approach to medical corruption, in other words, we will analyse this problem in a "Freakonomics" sort of approach.

One of the first complaints you hear is how doctors are just making too much money, and I am fundamentally against this claim. If anything the movement to decrease the doctor's salary has fowled up the purity of medicine, leading to a vicious cycle of decreasing the quality of healthcare in this country, and the only way to see this is to understand things from the doctor's eyes, which I truly believe most people just simply don't get.

Let me start with an anecdote that might help you to "get it". I have dated plenty of girls during my course in medical school, and while I would love to give them more attention and more of my time, right now school is my priority. The issue is this, if I want to be the best doctor I can be, my education must take precedence. I'll spend several hours a day or more dedicated to this end, and when I tell a someone I care about who wants to meet up that I can't because I have to study, initially it is fine. Many people that aren't in the medical profession can't simply grasp that we are as busy as I claim to be. This eventually leads to the end of the relationship. I am not complaining, I am just merely pointing out a small aspect of the larger picture, doctors really do sacrifice a lot and even if you can appreciate the fact that they do give up a lot, it still seems to be a challenge for the outsider to appreciate the impact this causes on their own lives. The point is, to enter medical school, there is simply no way you can hate what you do. You have to have a passion for medicine, so much so that you're willing to give up a lot, whether it be a relationship etc and this in itself should give you some idea of the selfless attitude you MUST have in order to become a physician. Not only is it required, but if you don't have these qualities, the system will filter you out, and make it very hard for you to achieve such an end.

The reason I mention all this is because as I said before people get angry about the large salary doctors get. This is not out of greed. As I mentioned above, if you're just in it for the money, there's almost no way you'll be able to become a doctor because the system will remove you, its just not viable if you don't have a passion for medicine itself. So if they aren't greedy, why should they get so much money? Let's start at the begining. The doctor is groomed starting in college. Most people want a doctor who has a solid education, so a smart college student is going to try to get in the best school possible. As an example, I got into Emory University, my family gave up a lot for me to go here, because they wanted me to get a great education and enable my the best chance of being a great doctor. Oh, I forgot to mention, Emory costs $40,000.00 dollars per year. By the time I finished I was $160,000.00 in the hole. Even with my competitive resume, I didn't get in on my first shot, and considering the cut throat nature of the medical application process, I decided to bolster my resume with a Masters degree. Oh, I forgot to mention that cost me $50,000.00. I finally got into medical school, and by the time I finish, I will have reached my goal of becoming a great doctor. Oh, I forgot to mention the fact that those 4 years cost me $200,000.00. Now, if I reach my goal of obtaining a residency in Manhattan, I will start my first year by making roughly $50,000.00 pulling very heavy hours. Not only does that salary absolutely not reflect the amount of work put into the job, but in Manhattan $50,000.00 will give you a little more leeway than treading water. In essence you'll be making slightly more than you'd spend. Oh, I forgot to mention residency is 5 years, a fellowship can be up to 3 years, at this point I'm in the late 30's and because you've been treading water, it was necessary to defer loans for 8 years. If you've been keeping track, I should be close to $600,000.00 in debt due to the interest on all those nice loans. I'll be around 36 by the time I land my first fat paycheck as a fully trained doctor, and I'll most likely have started a family maybe around this time, each kid roughly costs $200,000.00 over a lifetime. I won't get to see my family as much as I would like because I would be on call all the time. So everything said and done I'll be at least 40 before I get anywhere near the positive in the bank account I've been waiting all my life to even approach. Again, I am making this sound negative for a reason, I am not trying to complain, because I've known all my life what I am getting myself into, and I am a happy person about it. My point is to show the amount of investment needed, versus when it starts paying off to show why the doctor makes "so much money" or so it appears.

Within the last 30-40 years or so, the financial vice on doctors has been becoming more and more intensified. The "demonization" of doctors (as I mentioned a couple paragraphs ago) has led to society saying wait a second, why are we paying this so much if our healthcare system (things like medicare, and medicaid) needs more money? There's a couple reasons for this.

First there's the illusion as we've already reviewed that doctor's are making a lot of money simple input/output shows why this isn't true. Secondly, doctors are not a powerful entity. If you look at similar healthcare professionals such as dentists, they have relatively powerful lobbying groups defending their rights in congress. This explains why dentists have enjoyed a relatively stable salary level over the past several decades. On the other hand, the AMA is supposedly the doctor's voice in congress. One of the first things you learn as a doctor, is this isn't really true. It turns out the AMA makes a lot of its money by helping entities such as insurance companies and big pharmaceutical companies due to its unparalleled access to information about existing doctors. This body of information affords the AMA the privilege of making a huge profit by helping organizations that don't necessarily represent the best interests of the doctors and thus the doctor's voice has been weakened as insurance and pharmaceutical companies continue to spread their tentacles into the health system.

What this means is that whenever the government needs to tighten the screws on things such as medicare or medicaid, the easiest group to pick on, of course is the weakest group, the doctors. So instead of limiting insurance premiums or lowering the price of drugs (which wouldn't be the biggest tragedy for multi-billion dollar multinationals etc.) doctors get the punch from the government, this doesn't sound like much, but doctors suffer a lot more from this than you would think.


When you wake up in the morning and go to work, there is no chance that you question receipt of your paycheck. If your boss ever pulled a move like that, you'd be enraged. This kind of thing is unheard of, and is virtually absent according to the contracting standards of American society. However, consider the following scenario, imagine you had to see 20 patients a day, and 50 percent of those patients are covered by government backed insurance (whether that be medicaid or medicare etc). At the end of the week, the doctor sends in the insurance claims so that he or she can be paid. If the government is low on funds for that month, they will simply refuse the reimbursement. This sounds crazy, but its true, and I'm not understating the significance. It's not legal but it happens all the time and it's frankly disgusting. So the doctor is angry about this and decided to resubmit his claims. Second time through, he might get paid. However what this system allows for is the following, it sets up a hard to navigate system, that's extremely time consuming (a luxury most doctors don't have), that results in many, in fact up to 40% of the doctors not reclaiming their unpaid services. This means that by simply not paying doctors the first time the government saves 40%, and eventually pays out the other 60%. This is ridiculous, should doctors really have to play a cat and mouse game just to get paid the hours they put in for service at the price that was agreed upon? On top of this, even if the above scenario is not the case, there are many ways that insurance companies skirt paying doctors, for example if a doctor happens to omit a file that they followed a certain protocol, the insurance company can deny payment simply based on omission and may be reasonably justified, but where this becomes complex is on very small points. This seems simple enough, but its not, insurance companies will nickel and dime and find any loophole to deny doctors their rightful pay even when they are following protocol. It just gets messy very fast. So you might ask, why don't they hire a lawyer? An in-house lawyer would cost about as much money as a doctor would loose to the insurance companies on a yearly basis, if not even more. On a monthly basis we may be talking about numerous different claims the insurance companies might be denying, to attack each of these individually is simply not economically or temporally feasible. The insurance companies know this, and take full advantage. Again where's the representation for the doctors here? Why should anyone tolerate such abuse?


So again going back to the original point why do people think that doctors are blood sucking and money hungry a lot of the time? One story I heard involves a neurosurgeon who is taking out bank loans just to keep his practice in order. Most of his patients are insurance referrals, and he gets screwed just like all the doctors as I mentioned before. So would someone in this position of desperation order some unnecessary tests, do something medially unethical to catch up on the hundreds of thousands of dollars in loans accumulated since college? Maybe more so than if he/she wasn't in that position.

On top of all this we now have ObamaCare. I will not begin to even claim that I understand a 2000 paged document that at most 5-10 people in all of congress actually understand fully. However I think we can all agree that one general principle is to increase access of healthcare mainly based on making it required for citizens to have medical insurance that they pay for. Ok wonderful this isn't the worst idea, I am happy that more people will be able get health care that they need. WAIT. Did you just say more insurance company involvement? Some might say ok, now doctors are going to be paid more because now insurance companies will be billing more clients. That is good, I agree, more salary for doctors. WAIT, you want the same companies that have been screwing doctors all along to be responsible for a greater proportion of their salary? Sounds like a bad idea to me. We simply can't have a law like this unless we have some type of mechanism ensuring that what this legislation intended, actually occurs. What about some laws that ensuring that insurance companies pay doctors what they're supposed to be paid without all the BS? The way I see it, the whole system will appear to work for everyone except for the doctors. Which if you're not a doctor may not concern you that much. Well you should start thinking it will, because many more apathetic doctors are going to bill frivolous tests, and do frivolous things to make up for everything they're getting shorted. In other words more doctors will practice crap medicine to put food on the table for their own families. This pattern will trickle all the way down the chain, and decrease the overall efficacy of healthcare.

Obama if you want me to vote for you, tell me how you plan to protect the doctors of America? How to you plan to ensure your entire medical system doesn't become even more frivolous if you have no way to ensure doctors won't continue to become more apathetic to the illegal practices of American Insurance companies?

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