麻豆传媒

In this guest blog, , an attorney and transplant cardiologist at Rutgers University New Jersey Medical School in Newark, explains why he thinks it's time to talk money.

It's a sad situation when physicians earn significantly more money speaking about medicine than they do by actually performing complex, life-saving procedures.

On average, encounters with investment firms, pharmaceutical corporations, and/or device manufacturers regarding prescribing preferences or device choice generate reimbursement for the physician at a rate of approximately $500/hr; about the same as the rate that insurance companies reimburse physicians for chart review in malpractice cases.

This figure pales in comparison to what pharmaceutical firms pay "respected" academic physicians for a lecture, which can range from $1,500 to $2,000 for the hour.

Irrespective of whether one condones these activities, they do establish a fair market value for physician's time -- somewhere between $500 and $2,000 per hour. Many would argue that reimbursement at that rate is unconscionable.

Nonetheless, one must recognize that hourly reimbursement is not "take-home" pay. Office overhead including rent, salaries, and health and malpractice insurance premiums can reduce the figure by more than 50%. Moreover, the rate is not all that different than the billing rate of any respectable attorney and much less than the billing rate of Wall Street lawyers.

Recently, I cared for a critically ill gentleman with severe heart failure. Despite the presence of a balloon pump to support his heart, a ventilator to assist his lungs, and dialysis to replace his kidneys, his condition was worsening.

The likelihood of survival was poor. Placement of a durable "Cheney" device in the operating room was too high risk. Temporary mechanical cardiac assist was the sole option.

The procedure is challenging. The system (cannula) is large and can obstruct blood flow down the limb. A bypass circuit must be created to prevent gangrene.

The cannula must be advanced to the right upper chamber of the heart under x-ray and echocardiographic guidance. An opening is made between the two upper chambers of the heart, taking care to avoid perforating the heart or aorta as these complications can prove fatal. The cannula is advanced across the opening into the left upper chamber. A second cannula is placed in the other leg.

The circuit is connected, meticulously ensuring that no air enters the system, or brain damage may result. All cannulae must be secured, the patient transported to the ICU, the family spoken with, the procedure dictated, and orders entered.

Optimistically, the procedure takes 3 hours.

Imagine my surprise when informed that total reimbursement by Medicare for the procedure was $504.40 or $168.13/hr (prior to overhead) -- $28/hr more than our automobile dealer's repair rate and less than it costs for a routine dental cleaning. Had the surgeon implanted a "Cheney" device in the operating room, the reimbursement would have increased to only $285/hr.

Is it any wonder why children of physicians are increasingly choosing nonhealthcare-related professions? These young adults observe the lifestyles, complaints, and misgivings of their physician parents. They recognize the stress and frustration on their parents' faces and understand that the profession has devolved into a job. For those who do opt to enter the profession few aspire to open a practice.

The question isn't why not, but rather how could they?

Reimbursement is absurdly low. The credentialing process for the hospital, insurance companies, and Medicare can take months. Maintenance of certification programs, recertification examinations, ongoing professional education, annual CPR testing, preparation for OSHA inspections, and training in radiation safety, conscious sedation, domestic violence, and cultural sensitivity makes independent/private practice unsustainable from both financial and time points of view.

It is no wonder that more than 50% of cardiologists in the U.S. have affiliated with a hospital or healthcare system over the past few years.

Many might argue that the loss of private practice is no loss at all. After all, full-time physicians follow hospital-based protocols, are more cost-effective, reduce length of stay, and represent the model of the future. In fact, healthcare systems around the nation are emulating the Cleveland Clinic model.

However, a future with only employed physicians is not necessarily a rosy one. For centuries, medicine, has arguably attracted the "best and the brightest." It, like other professions, attracted those who sought autonomy and a modicum of prestige. If one worked hard and provided high quality service one could envision an emotionally satisfying and financially rewarding career.

Can we be certain that the same high quality individuals will be attracted to a salaried position where their income is entirely dependent upon the fortunes of the institution where they work?

Ideally, none of this should matter. We should all chose careers and professions based upon our passions. The elephant in the room is that such is not reality.

Our medical students are keenly aware that some specialties are more lucrative than others. A disproportionate number of them seek residencies in those specialties. We overhear their discussions. We recognize how difficult it is to direct them into primary care. Most continue to migrate to specialties and subspecialties. Interest and passion are part of the reason but the elephant remains -- income potential drives career choices -- and income potential continues to decline for physicians.

Is there anything fundamentally wrong with the goal of maximizing one's income? Isn't this what every working person seeks to do? Ask any union leader what he or she is trying to negotiate for the membership. An increase in salary is at the top of most lists.

Why does it seem morally reprehensible to suggest that physicians should be paid at the same rate as their legal and business counterparts? Perhaps from the perspective of the average American earning $28/hr a figure of $500/hr seems egregious. Few physicians are willing to publicly take the position that it is not.

Even fewer organized medical societies are willing to make such a statement. These organizations invariably fear not only negative public repercussions but the possibility that access to the policymakers' tables may be lost if they take a position contrary to what plays well to the public: doctors are overpaid.

Instead, these physician-led organizations tiptoe timidly around the issue. In the meantime, Medicare and third-party reimbursement continues to fall while healthcare executive compensation trends in the opposite direction.

Physicians (and specialists, in particular) have earned the right to be compensated commensurate with their education and training -- 8 years of undergraduate and medical school education followed by 3 to 7 years of residency and 2 to 4 years of additional fellowship training. Most physicians do not start their careers until their mid-30s and do so with over $200,000 in education debt.

Is $500/hr for intricate surgery really inappropriate when your life is on the line? Why are we as physicians so reluctant to publicly ask to be paid fairly by Medicare and the third-party payers? Frankly, $500/hr is a more than a bargain for the procedure described.

Physicians are not alone in facing the problem of reimbursement commensurate with education and training. Teachers, nurses, paramedics, and others may make the same claim.

So, I ask again -- is a life-saving intervention in the middle of the night worth only $168.13/hr while the individual repairing my refrigerator charges $300 for 45 minutes? Perhaps the time has come for a public discourse on the value of a professional's time.

CardioBuzz is a blog for readers with an interest in cardiology.

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