In the ongoing drama over health care costs in the United States, the frequent scapegoats are all those damn money-grubbing doctors.  Their high salaries are the reason health care spending is so high in America!  Right?

Well, I would agree that the money spent on physician salary and reimbursements is obviously a part of the total spending on health care, and thus a part of the problem.  But how big of a part?

Out of the total yearly expenditure on health care in the US, about 20% is payments to physicians for services performed (i.e. seeing patients, doing procedures, interpreting tests, etc).  On average, 50% of that money goes to overhead costs (rent, staff salaries, equipment, etc).  So, we end up with 10% of total US health care spending as a rough estimate of physicians’ take home salaries.

That’s not such a big piece of the pie.  Even draconian cuts to physician reimbursement would only shave a percent or two off total health spending.  And as physicians,  our overhead costs won’t change just because we get paid less for our services.

For example, let’s say that physician reimbursements were cut by 25%.  Our hypothetical Doctor X is a solo practitioner who typically receives about $500,000 per year in reimbursements with $250,000 in overhead costs to run his practice and pay his staff and the other $250,000 as his salary (before taxes, of course!)

All of a sudden, Dr. X’s reimbursements are cut by 25% to $375,000 per year, but his overhead costs stay the same (or more likely increase at the rate of inflation).  Now his take-home pay is cut by at least 50% to $125,000 per year.  Do you really want the person wielding the knife for your surgery to have just gotten a 50% pay cut?

But, hey, you might say that $125,000 per year is still pretty good!  Doctors in Europe make even less than that, right?

The problem with this comparison is that medical school in Europe is heavily subsidized and is essentially free.  Currently in the US, the average cost for 4 years of private medical school is $286,000.  If that medical school cost is taken out as loans and paid back at 8% interest over a 30 year loan period, that amounts to $2098 per month with about $469,000 paid in interest and $755,000 paid in total.  After taxes, a newly graduating doctor making $125,000/year could conceivably pay 6-7 years of his salary just paying back his loans.

Fortunately, the majority of graduates have less debt, but the average debt for medical school graduates has been between $150,000 and $200,000 in recent years.

In addition, doctors in Europe and most other first-world countries do not face the same malpractice litigation climate as American doctors.  The costs we pay for malpractice insurance (even if we never get sued) can be tens of thousands of dollars per year (and even hundreds of thousands for some high-risk specialties).

Finally, I do believe that anyone should be paid a salary that is in line with the value they provide.  Physicians sacrifice almost a decade of their lives to learning their art, and they have arguably the greatest positive impact on their patients’ lives of anyone.  I believe they should be well compensated for their services.

That being said, physicians who actively defraud the system or perform unnecessary procedures to make more money should be investigated and dealt with appropriately.

 

Today’s post is a bit more morbid than my usual topics, but I think it’s something that is very important to think about for everyone, no matter how young or how healthy you might be.

The old saying goes “the only two certain things in life are death and taxes.”  Whether we like it or not, we are all going to die one day.  I think it only makes sense that we give a little bit of thought to how we would like to die, and then (just as important!) communicate our wishes to our families.

The large majority of people would prefer to die in their own homes, but in modern America, the majority of people die in the hospital, usually with multiple invasive tubes and iv lines inserted into their bodies.

Why does this happen?

The reasons are many, but here are two important ones.  First, most people don’t really want to think about the end of their lives, and even if they do, they don’t want to upset their spouses or families by talking about their wishes.  Second, once someone is very sick with a terminal illness and can no longer communicate their wishes, the usual instinct of their family members and doctors is to err on the side of intervening and treating the illness.

So, people who would have rather died peacefully in their own beds end up being transported to the hospital, kept in the ICU for 2 weeks, had breathing and feeding tubes placed, and then die in the hospital after racking up 6 figures in pointless medical bills.

If you would want to have everything done to keep you alive in that situation, you have every right to that treatment!  But most people with a terminal illness (meaning that your doctor believes you have a non-curable disease and likely will die within 6 months) do not want heroic efforts to keep them alive.  Most people in that situation are much more concerned with staying comfortable and being able to appreciate their last few months, weeks, and days with their loved ones.

For patients with terminal illnesses, Hospice care can be a great blessing.  Hospice is an organization that provides counseling, comfort care, and nursing for terminally ill patients at home or in the hospital.  The goal of Hospice is not to cure the disease but rather to keep each patient as comfortable, alert, and interactive as possible through their last months.

Although the mission of Hospice is not to prolong life, numerous research studies have shown that patients in Hospice actually do live longer (and with a better quality of life) than patients who “want everything done.”

I am fortunate to be in a specialty without very many terminally ill patients, but I do see some patients with head and neck cancers who cannot be cured with surgery, radiation, or chemotherapy.  For these unfortunate patients, I strongly urge them to think about Hospice.

But even before, everyone should think about their end of life wishes.  Particularly so if they are diagnosed with a life threatening illness, such as cancer, heart disease, or COPD.  The time to think about it is when you feel well and have your wits, not when you are on death’s door.

The state of Texas has a very good information page that will walk you through the decisions you need to think about.   Link to webpage here.  It provides templates for various legal documents that can record your wishes for when you are unable to communicate them.  The PDF file at the bottom of that page called “Thinking Ahead: My Way, My Choice, My Life at the End” is excellent.

Every person will have to decide for themselves if they want to draft an official advanced directive and medical power of attorney to ensure their wishes are followed.  Most of the time, doctors will ask your family what you would want done if you can’t communicate your wishes.  As long as you’ve discussed your wishes with your family (and they are all on the same page), an official advanced directive may not be necessary.  But in my opinion, you’re better safe than sorry to put it down in writing.  That way, if your family is very emotional and might want to be more aggressive with your treatment, your wishes will be there in writing for everyone to see.