Doctors Are Government Employees
So why expect good service?
Doctors speak frequently among themselves about problems in medicine: decreased collections; inability to spend more time with patients; difficulty getting consults from specialists, especially for Medicare/Medicaid patients; enormous time wasted with patients who aren’t really sick (sometimes they’re old and lonely; sometimes they’re unemployed with nothing else to do — visits to the doctor for the poor are often a family affair, with three generations crowding the waiting area); the incredible wasted resources in the emergency department. (Due to federal EMTALA laws, no one needing emergency care can be turned away from an ER.)
But there’s one thing doctors never talk about, even though it easily explains the problems patients have in getting good treatment and doctors have in providing it:
Doctors are government employees.
I’m not talking about only the doctors that work in the Veterans’ Administration or the hospitals run by the Bureau of Indian Affairs. I’m not talking about the training centers known as county hospitals, where students learning the practice get to make mistakes on poor people prior to actually going out in the real world.
I’m talking about all doctors — because the government contributes about 50 percent of all health care dollars to physician pay. And another 40 percent is contributed by third-party payers that are themselves highly regulated by government and routinely follow the government’s lead in pricing.
People in the United States don’t need to have it explained to them why FedEx and UPS do a better job than the U.S. Postal Service. They know why they stand in long lines when they use USPS and face surly unpleasant employees behind the counter. It’s a government monopoly. For years, the post office I frequent had a number dispenser, like at a deli. You’d wait for your number to be called. I would typically walk in, pull the number, say, for example, 57, and find they were currently calling 13. Recently, this technique was discontinued. I asked the postal employee why, and he explained studies showed the system made people feel they were waiting too long, so the Postal Service got rid of the number dispensers — not to speed things up … just to make it harder to know how long you had to wait.
People in the United States don’t need to be told why their garbage pickup is not always as dependable as their dry cleaning pickup. They know one is paid for out of taxes while the other is paid for out of pocket, that one is a monopoly you have no choice but to use while the other is a service you can take or leave, or change. They know the dry cleaning company will never berate them if they don’t pre-sort their clothes properly before pickup.
But the fact is, many post office employees are not happy either. Like doctors, they feel hampered by regulation; like doctors, they often find themselves drowning in paperwork. Every one of them sees inefficiencies they have to live with because the system doesn’t provide easy ways to correct or eliminate them.
Why should medicine be different? Because doctors are smart? Not smart enough, it seems, to avoid a field thoroughly transmogrified by government regulations. Because health is important? So is sanitation and communication. Epidemiology tells us improvements in the former account for a significant increase in longevity in the last century, and communication is so important we have essentially eliminated much of the post office’s work by a technological fix the government doesn’t control: email.
If doctors and patients want better health care, there’s an easy way to achieve it. Doctors have to start working only for patients, and patients have to start paying doctors for their services.
Granted, it’s not quite as simple as that sounds. Here are two quick difficulties:
- Doctors are trapped in a system that likely overtrains them. This lowers supply and maintains a high physician income. That could change over time as people refuse the high fees, but only to the detriment of doctors already out of training.
- Doctors have to operate on patients in hospitals or surgi-centers, and both are highly regulated by state and federal governments, making efficient and cost-effective service more challenging.
But the first step is clear: Don’t expect good quality service from a government employee. And don’t expect, if you are a government employee, to be able to provide good quality service.
Comment by Rich Matarese on 9 August 2010:
–
I’d hazard a guess that Dr. Levy is not only a physician but a primary care grunt like me. That bit about “difficulty getting consults from specialists” is a front-line practitioner complaint, not the lament of a secondary or tertiary specialty guy.
What Dr. Levy fails to mention (and this is the proverbial eight-hundred-pound gorilla in the phone booth) is that doctors can be deprived of the exercise of their right to make a living using their training (and everything else they’ve invested in the practice of medicine) by the politicians and bureaucrats of civil government.
You can have your license jerked.
The right to make a living is critical. If one spends one’s entire life learning how to do one thing – and do it well – the awareness that some politician in public office can utterly ruin you simply out of malice….
Well, that’s a damned scary situation, is it not?
I don’t know bout Dr. Levy, but the first lecture in my med school course in Medical Jurisprudence, the instructor opened with the following statement:
“There is not a single one of you in this room who will not do some thing – every day – in the treatment of patients which can cause you to lose your license to practice medicine.”
That got our attention, by God.
Because it was true, just as true as Cardinal Richelieu’s famous observation: “If one would give me six lines written by the hand of the most honest man, I would find something in them to have him hanged.”
It’s not simply that “Doctors have to start working only for patients, and patients have to start paying doctors for their services.”
It’s also critically important that civil government as an agency – and politicians as the people controlling civil government – cannot be allowed to determine whether or not a doctor is fit to work for patients, and whether patients are allowed to consult with a doctor to provide them the care they desire.
–
Comment by Robert Charron on 9 August 2010:
The USPS is a favorite whipping boy, people routinely denounce it, but I have found postal employees very courteous and pleasant and helful. UPS and Fed-Ex skim the profitable part of USPS’s trade so of course are profitable. I found they charge quite a bit more than USPS to mail a package and their service is not as good. Moreover the USPS has to deliver mail and provide service to rural areas and isolated places that increase its costs, but the USPS was founded to provide what was and is an essential service to all parts of the U.S., not to make money. I am not an employee of the USPS nor are any of my relatives. People seem to forget this aspect. Our fee for service scheme under which doctors operate has serious deficiences. The Cleveland Clinic which is one of the best clinics in the U.S., and one of the most efficient economically has all its doctors on a salary. This has worked out well. The scheme of having a number of insurance companies in charge of medical care is not efficient. Knowledgeable people estimate as much as 1/3 the medical costs are administrative expenses. When I was a child in the thirties the mining company where I lived in the U.P. provided a hospital and doctors for its employees at a very nominal charge. My birth cost my parents $25. The doctors and care were excellent. In rural WV a poor family had a son born with a condition that required hundreds of thousands of medical care while the child was growing. We held dinners for them that netted maybe $300. One more point, a significant number of mortgage defaults have been caused by excessive medical bills. I think this calls for some thinking outside “the box.” Practicing medicine is not something that lends itself to conventional market operations. I hear horror stories about single payer systems, I can give personal horror stories of my families experiences with doctors in our present system. In the interest of full disclosure, I have a son who is a surgeon, but I don’t know what his views are on theis subject.
Comment by George Schwappach on 9 August 2010:
Well, your pleasant experiences with USPS workers is probably due to the fact that you never ask them the tough questions. Next time you are at the PO, why don’t you ask them “have you guys considered a drive thru?” Or, when the christmas holidays come, “Hey, how about staying open till midnight, like walmart”. Just querry them why they don’t operate like a successful business, and you will learn a differt temperment from those USPS folks.
If you really want to get an insideres sence, make an improvment sugestion that the clerk agrees with. Then recomend that they turn this idea in for merit credit. If they are open, they will explain how the organization punishes those who ‘make waves’ with new ideas. No, these people are not happy with their work. If you really believe they are, then you are blind to the reality of a government job.
I know, I held one until my integrity made me leave. My religion requires me to do my best. When all your bosses are telling you to slow down because we will run out of work. Take it easy and just let things slip by. That was it for me.
Comment by Larry Ruane on 9 August 2010:
Robert, your comment leaves me somewhat confused. You point out how expensive medical care is today and conclude that medicine does not lend itself to conventional market operations. But the point of Dr. Levy’s article is that the current medical system is almost entirely run by the government, not the market.
I agree with you; we need some outside-the-box thinking. For example, why don’t we try letting the market provide medical care (as it for the most part did when you were born for $25)?
Comment by norman on 9 August 2010:
With the congressional elections coming up in Novermber, the root cause of government interference in the economy could be eliminated. If you firmly believe that the current situation is broken and corrupt, then do not re-elect the incumbent candidate. Don’t delude yourself Dr. Levy, the majority of Americans are content with goverment just as it is. Most are infavor of a little more stimulus from the Federal Reserve. Medical payments rank far behind extended unemployment benefits. Being on Medicare, the current situation suits me just fine, but I’ll vote Libertarian.
Comment by Brian on 9 August 2010:
As a fellow physician, first I must say that I agree with your assessment as written. My only issue is that you don’t elaborate enough on the ideas you present. I’d like to contribute a little more to your thinking for anyone else who may be reading. I don’t often post responses, and never check back, but your post resonated with the very same topic I’ve been pondering for a few years now ever since I started educating myself on libertarian and freedom-minded political and economic thought.
As a newer physician, out of med school for 9 years, I never had the opportunity to experience what medicine “used to be.” It’s always been heavily regulated by the government. I have worked in private practice, non-profit community organizations, and just started working for the Veterans Administration (more on that in a bit). Not only are we controlled by the payment source, Medicare/Medicaid and heavily regulated private insurance that is forced to operate the same way, we are directly regulated by the government itself. This is so obnoxious that it is very difficult to practice even if one were to do so for free. This is but one consequence of government regulation, that providing free, volunteer care is almost impossible due to all the expense and time required to do so to the government’s arbitrary, and often counterproductive, standards.
I can only speak to my own motivations and those of a few close friends in med school, but I was not yet aware of the governmental regulatory burden involved in medicine. I was fresh out of college, like most of my classmates, and was more focused on the goal of making the next good grade and, on a grander scale, of helping those who are sick get better. It wasn’t part of anyone’s calculations that their ability to do wasn’t going to be mostly determined by ones inherent skill, quality of training, and work ethic. No one really expected that to only account for a small percentage of one’s success, and that the greater challenge would be one’s ability to navigate the labyrinthine regulations on every aspect of medicine and still break even, much less profit.
Now, in the real world, newly minted doctors come out of training owing hundreds of thousands of dollars in student loans. Money they have to pay back with interest while still seeking loans to start a new practice or while starting out at long hours and low pay (often less than minimum wage, if calculated by the hour) as you gain experience and practical skill while shedding the excess burden of interesting, but ultimately useless, “overtraining” to which you alluded.
It’s so bad that I have been turning prospective physicians away from medicine as best I can based not only on current realities, but on expectations of Obamacare worsening it exponentially.
The myth of the high paid physician is still perpetuated, and often serves as one of the attractive aspects of pursuing a career as a doctor. The reality is that the average physician salary has been plummeting over the past 30 years. For example, an average starting salary in my specialty 15 years ago was about $250,000. Today it’s around $150,000. That’s gross, not net. That’s not adjusted for the fall in the value of the dollar, either. Out of this comes about $10,000 for malpractice insurance, $60,000 for office overhead costs, thousands for licenses, fees, etc. You end up with about $60-$70,000 take home. That’s fine except you work about 80 hours a week to get that. All of this was less costly 15 years ago. This is only intended for illustration, not sympathy. We chose this profession. That’s the consequence.
This is why, in part, there has been a huge exodus among physicians in private practice towards fee for service models where the doctor provides the service and the patient pays the full fee. The doctor doesn’t file insurance, and maintains a limited office staff. And since without payment, no service is rendered, he is guaranteed payment. By so doing, he can cut costs and overhead dramatically, spend more time with each patient, and still offer the service for less money than before. The patient walks away happier and with better care, but with the task of filing his own insurance claim (a nightmare of its own).
Others, like myself, have looked for shelter elsewhere. Though I despise the government, I figure the safest place to hide from the monster, when no place is safe, is in the shadow of the beast itself. What politician in his right or left mind would propose cutting veterans’ benefits? Plus, in my sense, I owe these poor soldiers who have been misused by our government as cannon fodder for too long, something for not having fought hard enough to prevent people like Bush and Obama from getting into power in the first place.
Now, for sake of comparison, consider the other large system of medical care in this country. One with far less government regulation (though still some), much the same range of illnesses and treatments, virtually no insurance, and much greater freedom of choice in provider. Veterinary medicine. Pets are part of the family, and most people spare little expense on their cats or dogs, and yet we are able to take them to a vet appointment once a year for around $100, and our pets aren’t dying in massive numbers for lack of care. If a treatment if choice is expensive, we have the option of paying it or choosing a less expensive alternative. If money is no object, the available treatments are nearly unlimited and far greater than those for the same human illness often because of the availability of cutting edge procedures that may or may not become proven techniques. For example, MRI and CT (yes, “cat scans”) were first widely available to veterinarians years before human use became common.
Veterinary medicine is, in essence, a more free market medical care system that costs far less and provides comparable results mostly because of less government interference. If you don’t like your vet, you just go to a new one. No government mandated or insurance mandated list of providers.
Comment by Dave Narby on 9 August 2010:
Wow…
Brian, I’d love to be able to quote you. Could you contact me at my website (I’m a candidate for state assembly)?
Dave Narby
Comment by Brad on 9 August 2010:
For the patient, the consequences of having a physician who’s a government employee can be a problem. Let’s say a retiree has a stroke. Recovery might be better with prolonged Rehabilitation, and, having the money, the guy wants it. He says, “No problem, I’ll pay for it.” Well, government doctors can’t take money outside of their government practice. That’s a no-go. He says, “I’ll sue the government.” Good luck. He says, “Well, maybe I’d be eligible for prolonged rehabilitation if the doctor fudges the facts a little.” Well, that’s potentially a felony…
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Comment by Charles Gallagher Jr. on 10 August 2010:
If medical bills became the responsibility of the patient to pay and the patient was then responsible for obtaining his reimbursement from insurance or medicare or TRICARE we would initially have a mess. But we would also have enough of a public outcry that system improvements would be more likely than they are under the current processes.
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Comment by D. Saul Weiner on 10 August 2010:
Reading Brian’s saga, it is clear that doctors today are getting squeezed financially and smothered in paperwork. I am discouraging my daughter from going into medicine.
Decades ago the MD’s obtained great windfalls from the legal privileges seized by the AMA and later, from the Medicare boondoggle.
How unfortunate that today’s doctors are paying the price for this legacy of fascism.
It reminds me of the dynamics of the Boom/Bust cycle that the Austrian economists talk about. People are euphoric during the boom phase and cannot be troubled to consider whether or not the “good times” are creating problems down the road. Then comes the bust and they are left to wonder, “WTF?”
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Comment by steve mc on 12 August 2010:
The reason UPS and FedEx don’t deliver mail (though they deliver packages to ‘rural’ areas, ( I live in one, and drive on remote backwoods dirt roads, and usually the only drivers I see are FedEx and UPS driver’s other than myself. My wife and I actually have fun laughing about how the UPS drivers are ‘everywhere’ ), but to finish the thought, the ONLY reason UPS and FedEx don’t deliver mail is they are NOT ALLOWED to by the Federal Government. If they could, they would happily deliver mail, but ONLY the USPS is allowed to deliver mail. Oh, and USPS is legally bound to NEVER fire a single employee, ever. Legally they can never layoff a single employee, EVER. It’s the LAW.
Comment by James Madison Fan on 12 August 2010:
Steve,
You’re right on the mail monopoly and wrong on the firing. Sometimes Postal Workers do stuff to mail (hide it, trash it, etc.) and when it is discovered they are fired.
In addition to this they have to accept transfers to within 500 miles of their current assignment or face termination. The USPS is about to start using automatic sorting machines so their workers will not need to “case” their routes. This means longer delivery routes. A lot of older delivery workers are trying to retire, get desk jobs, etc. in an effort to avoid some of these longer routes but the decrease also means that many workers (last in first out) will be forced to move to newer offices where they do not have enough personnel.
Comment by jonathan v wright md on 4 December 2010:
If you’re looking for a physician who will WORK FOR YOU, who accepts no third party payments of any kind (except parents for children!)contact the office and/or check the website of of a member of the American Association of Physicians and Surgeons (www.aapsonline.org , a highly skilled “conventional” medical group of MDs and DOs) or the American College for Advancement in Medicine (www.acamnet.org), the International College of Integrative Medicine (www.icimed.com, and the American Academy of Environmental Medicine (www.aaem.com). The latter three are highly skilled MDs and DOs practicing both “conventional” and “natural” (aka “integrative”)medicine.
The very large majority of these several thousand physicians refuse to participate in government or insurance company programs, which by their very nature limit the physician’s ability to do the best he or she knows how to do for their patients.
Be well–on your terms, working with a doctor who WORKS FOR YOU,
and not according to government or insurance company restrictions, regulations, and edicts!
j v wright md
tahoma clinic
renton, washington
http://www.tahomaclinic.com
LP Member since 1973
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