Does America Have the Greediest Doctors?

Yesterday, The New York Times published a mind-boggling investigation into a way some physicians have found to hit patients with absolutely mind-boggling bills for not just routine procedures, but the involvement of doctors in their care that they neither asked for nor knew about until they got the bill. However widespread a practice this is, I'm going to argue that what we have here is not a few bad apples but a problem of culture. But first, here's an excerpt:

In operating rooms and on hospital wards across the country, physicians and other health providers typically help one another in patient care. But in an increasingly common practice that some medical experts call drive-by doctoring, assistants, consultants and other hospital employees are charging patients or their insurers hefty fees. They may be called in when the need for them is questionable. And patients usually do not realize they have been involved or are charging until the bill arrives.

The practice increases revenue for physicians and other health care workers at a time when insurers are cutting down reimbursement for many services. The surprise charges can be especially significant because, as in Mr. Drier's case, they may involve out-of-network providers who bill 20 to 40 times the usual local rates and often collect the full amount, or a substantial portion.

That's right, 20 to 40 times the standard rate. The article tells about one man who got a bill for $117,000 from a doctor who assisted in his neck surgery, and a woman who was billed $250,000 by two plastic surgeons who closed an incision during her back surgery. While this may not meet the definition of criminal fraud, it sure sounds like a scam. And if you thought I was going to blame it on our profit-driven health system, well you're right.

As I see it, there are two problems here, one institutional and one individual. Doctors in England or Germany or France or Japan aren't trying to get away with charging $250,000 for closing an incision not just because it probably would never occur to them, but because even if they did it would be impossible. The health care systems in other highly developed nations range from the nearly totally socialized, like Great Britain's, to ones that run on what look a lot like Affordable Care Act exchanges, where people are privately insured. But every one of them is more highly regulated than ours when it comes to what can be charged for procedures, for drugs, for therapies, and for pretty much every interaction you have with the health care system.

The result isn't just that those countries spend far less overall than we do for health care, with outcomes as good or better than we have, but also that certain kinds of spectacular greed just aren't possible. Our health care system, in contrast, not only provides multiple points at which huge profits can be extracted, it's built around the idea that huge profits should be extracted, that medicine is an enterprise whose primary goal is to make money.

That's true of insurance companies, hospitals, device makers, and yes, doctors. And that's where we get to the individual problem. In the United States, we make a bargain with our physicians. It goes like this: You'll have to go into enormous debt to get that "M.D." after your name, but once you do, the promise of riches awaits. In other countries, they make a fundamentally different bargain. It says: The taxpayers will pay for your medical education, and once you're a doctor you won't get stinking rich. You'll do quite well, make no mistake, but medicine won't be a path to the .001 percent.

While these two bargains might look similar—we'll pay our doctors on the front end or the back end—they aren't anything alike. The problem is that the bargain we strike inculcates a culture of entitlement among at least some physicians, a culture that says that because they paid so much for their education and their occupation gives them such exalted status, they're entitled to make enormous amounts of money. I'm sure the doctor who billed that guy $117,000 for a few hours of his time thinks he charged a completely fair rate, just as everyone who cooperates to charge a six-figure fee for joint replacement surgery that can be done in Belgium with the same equipment for $13,660 probably thinks they're being fair. After all, it's what the market will bear, right?

We should be careful not to paint with too broad a brush. There are doctors who do extraordinary work for middle-class salaries—a family practice physician working in a free clinic in the Appalachian hills makes a lot less than a Beverly Hills cardiothoracic surgeon does. But on average, American doctors are the highest-paid in the world, and it's not because they're so much better at their jobs than their counterparts in Canada or Sweden. When the average American orthopedist makes $413,000 a year but only 45 percent of orthopedists think they're being fairly compensated for their efforts, something is seriously wrong. The practice described in the Times article is a product of a system in which there are gobs of money being made and doctors are told in a hundred ways, subtle and otherwise, that they ought to get their share. We shouldn't be too surprised when some of them find particularly creative ways to do it.

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