Better (14 page)

Yet it seems churlish to complain. Here are the facts. In 2003, the median income for primary care physicians was $156,902. For general surgeons, like me, it was $264,375. In certain specialties, the income can be a good deal higher. Busy orthopedic surgeons, cardiologists, pain specialists, oncologists, neurosurgeons, hand surgeons, and radiologists frequently earn more than half a million dollars a year. Maybe lawyers and businessmen can do better. But then most biochemists, architects, math professors earn less. In the end, are we working for the profits or for the patients? We can count ourselves lucky that we don't have to choose.

There are, however, those who do choose--and manage to earn considerably more than most. I talked to one such surgeon. He had practiced general surgery at the same East Coast hospital for three decades. He loved his work, he said. He did not have an unduly heavy schedule. His office hours were from nine thirty to three thirty on just one day a week. He did about six operations a week. He had been able to develop a
special interest and skill in laparoscopy--performing operations through tiny incisions using fine instruments and a fiber-optic video camera. And he no longer had to cover midnight emergencies. I asked him in some roundabout way how much he earned doing this. "Net income?" he said. "About one point two million last year."

I had to catch my breath for a moment. He'd made more than a million dollars every year for at least the past decade. I wondered how it was possible, or acceptable, to earn so much for doing general surgery. He was perfectly aware of the reaction. (As was his hospital, which did not want his or its name to appear in print on the subject.) "I think doctors shortchange themselves," he said. "Doctors are working for fees that are similar to or below those of plumbers or electricians"--people who, he noted, don't require a decade of school and training. He doesn't see why doctors should let insurance companies dictate their compensation. So he accepts no insurance. If you decide to see him, you pay cash. If you then want to fight with your insurer for reimbursement, that's up to you.

The fees he charges are what he finds the market will bear. For a laparoscopic cholecystectomy--removal of the gallbladder, one of the most common operations in general surgery--insurers will pay surgeons about seven hundred dollars. He asks for eighty-five hundred dollars. For a gastric fundoplication, an operation to stop severe reflux of stomach acid, insurers pay eleven hundred dollars. He charges twelve thousand dollars. He has had no shortage of patients.

It's not clear how easily others would replicate his success. After all, he works in a large metropolis, where many people have either incomes or insurance policies generous enough to
accommodate his fees. He's also something of a star in his field. "I know in my heart that I can do things that other surgeons can't," he told me.

But suppose I did what he did--refused to deal with insurance and charged what the market would bear. I would not make millions, but I could make a lot more than I otherwise would. I'd avoid all the insurance hassles, too. Still, would I want to be a doctor only to those who could afford me?

Why not? the surgeon was asking. "For doctors to think we have to be altruistic is sticking our heads in the sand," he told me. Everyone is squeezing us in order to make money, he said--everyone from the supply companies that we pay to the insurers who are supposed to pay us. In 2005, "the CEO of Aetna's compensation [was] ten million dollars," he pointed out. "These are for-profit companies. Insurance companies make money by withholding reimbursements to physicians or by not approving payment for a service we've provided." To him, the question is why we deal with them at all. In his view, doctors need to understand that we are businessmen--nothing less, nothing more--and the sooner we accept this the better.

His position has a certain bracing clarity. Yet, if this is purely a service-for-money business, if doctoring is no different from selling cars, why choose to endure twelve years of medical training, instead of, say, two years of business school? The reason has to be that doctors remain at least partly motivated by the hope of doing meaningful and respected work for people and society. Thus the responsibility most of us feel to take care of people even when their insurers exasperate us or when they have no insurance at all. If we fail ordinary people, then the notion that we do something special is gone. I can
understand wanting to escape the insurance morass. But isn't there some other way around it?

I
N 1971,
a thirty-three-year-old internist named Harris Berman decided to do things a little differently. He and a friend who had just completed his general-surgery training moved back to their home state of New Hampshire, to the town of Nashua. They joined up with a pediatrician, a family practitioner, and an obstetrician. Together they offered health care to patients for a fixed annual fee, without any bills to insurance companies. It was a radical experiment. They paid themselves fixed salaries of thirty thousand dollars a year, a modest income for a doctor at the time, with no differences between specialties. They also bought reinsurance coverage to pay for costs that exceeded fifty thousand dollars, as Berman remembers it, in case a patient developed a catastrophic illness.

The scheme worked. Berman, who is now sixty-eight years old, told me the tale. They called themselves the Matthew Thornton Health Plan, after a physician who was one of New Hampshire's three signers of the Declaration of Independence. They were essentially an HMO, though a very tiny one. Within a short time, about five thousand patients had signed up. The doctors thrived, and there were remarkably few hassles. In the beginning, they didn't have any subspecialists, so when patients were sent to an ophthalmologist or an orthopedist the Thornton doctors had to pay for the visits. Eventually, they asked the specialists to accept a flat fee each month and dispense with the paperwork.

"Some accepted," Berman said. "And the effect on care
was remarkable. The urologists, for example, suddenly became interested in having us understand which patients they really needed to see and which ones we could take care of without them. They came down and gave us talks--how to work up patients with blood in the urine and decide which ones you had to worry about. The ophthalmologists came down and told us how to take care of itchy eyes and runny eyes. They weren't going to make more money seeing these unnecessary patients, and they found a way to make sure we became more efficient."

After a few years, the Matthew Thornton Health Plan started to be cheaper than other insurers. Employers caught on and enrollment soared. Berman had to bring in more doctors. That's when things got more complicated. "In the beginning, we were all committed," he said. "We worked hard--long hours, a lot of dedication, young and hungry. Then, as we started to get bigger and bring in more staff, we found that others joined for other reasons. They liked the salaried lifestyle--the idea that being a doc could be a job rather than a day-and-night commitment. Some were part-timers. We began to see people looking at their watches as five o'clock approached. It became clear that we had a productivity problem." Also, when they tried to bring in specialists to work full-time with the group, the specialists refused to accept the same salary as the others. In order to get an orthopedic surgeon to join, Berman had to pay him considerably more than what everyone else got. It was the first of many adjustments he had to make in how and what to pay his fellow physicians.

Over the course of thirty years, Berman told me, he ended up trying to pay physicians in almost every conceivable way. He'd paid low salaries and high salaries and still watched
them go home at three in the afternoon. He'd paid fee-for-service and watched the paperwork accumulate and the doctors run up the bills to make more money. He'd come up with complicated bonus schemes for productivity and given doctors budgets to oversee. He'd given patients cash accounts to pay their doctors themselves. But no system was able to provide both simplicity and the right balance of thriftiness and reward for good patient care.

By the mid-1980s, sixty thousand patients had joined the Matthew Thornton Health Plan, mainly because it had controlled its costs more successfully than other plans. It had become the second-largest insurer in New Hampshire. And now it was Berman and his rules and his contracts that the physicians complained about. In 1986, Berman left Matthew Thornton, and it was later taken over by Blue Cross. He went on to become the chief executive officer of Tufts Health Plan, one of New England's largest health insurers (where he earned a CEO's income himself). The radical experiment was over.

I
N 2005,
the United States spent more than two trillion dollars--one-sixth of all the money we have--on health care. This amounted to $7,110 per person. Government and private insurance split about 80 percent of those costs, and the rest largely came out of patients' pockets. Hospitals took about a third of the money; clinicians took another third; and the rest went for other things--nursing homes, prescription drugs, and the costs of administering our insurance system. Americans seem to be reasonably happy with their care, but they haven't
liked the prices--insurance premiums increased by 9.2 percent in 2005.

Physicians' after-expense incomes are a fairly small percentage of medical costs. But we're responsible for most of the spending. For the patients I see in the office in a single day, I prescribe somewhere around thirty thousand dollars' worth of medical care--in the form of specialist consultations, surgical procedures, hospital stays, X-ray imaging, and medicines. And how well these services are reimbursed inevitably affects how lavish I can be in dispensing them. This is where money-mindedness becomes inescapable--and likewise the struggle between doing right and doing well.

I remember, twelve years ago, getting the bill for the heart surgery that saved my son Walker's life. The total cost, it said, was almost a quarter-million dollars. My payment? Five dollars--the cost of the copay for the initial visit to the emergency room and the doctor who figured out that our pale and struggling boy was suffering from heart failure. I was an intern then and in no position to pay for any significant part of his medical expenses. If my wife and I had had to, we would have bankrupted ourselves for him. But insurance meant that all anyone--either us or his doctors and nurses--had to consider was his needs. It was a beautiful thing. Yet it's also the source of what economists call "moral hazard": with other people paying the bills, I did not care how much was spent or charged to save my child. To me, all the members of the team deserved a million dollars for what they did. Others were footing the bill--so it's left to them to question the price. Hence the adversarial relationship patients and doctors have with insurers. Whether
insurance is provided by the government or by corporations, there is no reason to think that the battles--over the fees charged, the bills rejected, the preapproval contortions--will ever end.

Given the struggles over payment, what's striking is how substantial medical reimbursements have continued to be. Physicians in the United States today remain better compensated than physicians anywhere else in the world. Our earnings are more than seven times those of the average American employee, and that gap has grown over time. (In most industrialized countries, the ratio is under three.) This has allowed American medicine to attract enormous talent to its ranks and kept doctors willing to work harder than members of almost any other profession. At the same time, we as a country have shown little concern for the uninsured. One American in seven has no coverage, and one in three younger than sixty-five will lose coverage at some point in the next two years. These are people who aren't poor or old enough to qualify for government programs but whose jobs aren't good enough to provide benefits, either. They face difficulty finding doctors who will treat them, unconscionable rates of bankruptcy from health care bills, and a proven increased likelihood that problems such as high blood pressure, heart disease, appendicitis, and cancer will go undetected or inadequately treated. Our byzantine insurance system leaves gaps at every turn. Some day soon that must change.

A
FEW DAYS
after the chairman of surgery offered me the job, I returned to his office and named my figure.

"That'll do fine," he said, and we shook hands. Now I am the one who's too embarrassed to say what I earn. We talked for a while afterward: about how to fit research in, about how many nights I'd have to be on call, about how to keep time for my family. The prospect of my new responsibilities filled me with both exhilaration and dread.

As the meeting was ending, though, I realized that there was one final important question I had not brought up.

"What are the health insurance benefits like?" I asked.

O
n February 14, 2006, a United States district court issued an unprecedented ruling concerning the California execution by lethal injection of murderer Michael Morales. The ruling ordered the state to have a physician, specifically an anesthesiologist, personally supervise the execution or else to drastically change the standard protocol for lethal injections. Under that protocol, the anesthetic sodium thiopental is given at massive doses that are expected to halt breathing and extinguish consciousness within one minute after administration; then the paralytic agent pancuronium is given, followed by a fatal dose of potassium chloride. The judge found, however, that evidence from execution logs showed that six of the previous eight prisoners put to death in
California had not stopped breathing before technicians gave the paralytic agent; the finding raised a serious possibility that the prisoners had experienced suffocation from the paralytic, a feeling much like being buried alive, and felt intense pain from the potassium bolus. This experience would be unacceptable under the Constitution's Eighth Amendment protections against cruel and unusual punishment. So the judge ordered the state to have an anesthesiologist present in the death chamber to determine when the prisoner was unconscious enough for the second and third injections to be given--or to have a general physician supervise an execution performed with sodium thiopental alone.