Are my doctors really CHEATING me?
As a health care provider and an advocate for my patients, of course I want to Make America Healthy Again. (What do you think this web site is trying to accomplish??). But I have to express my concern with the language used here. That fourth word, “again”, leads us to believe two notions which should be accepted as facts:
America was healthy before.
America is NOT healthy now.
Using these assumptions as a basis for argument, which 99.99% of physicians and other healthcare providers vehemently disagree with, America (under the leadership of our elected and appointed political officials) seeks to understand what went wrong?
The conclusion: The health care system is undeniably corrupt and is cheating you.
I share the many concerns of our administration, and I agree there is MUCH we can improve in this health care economy. However, I find this conclusion disgusting. Still, for the sake of argument, let’s review a few of the main concerns that have driven this argument.
QUESTION 1: How are doctors paid?
Doctors in the United States are primarily compensated for their time through a combination of salary, insurance reimbursement, and in some cases, government payments. Most private practitioners receive payments from insurance companies or government programs like Medicare and Medicaid based on the type and volume of patient visits and procedures performed. These compensation models generally reflect the level of training, experience, and specialty of the physician, as well as the regional demand for medical services. Employed physicians may also receive a salary with productivity incentives.
What does this mean?
In full disclosure, I get productivity incentives. All of my colleagues do, too. And we work at a major academic not-for-profit medical institution which treats a catchment of >2 million Americans. This is very common. Productivity incentives mean I am expected to see X number of patients every year, with a certain degree of medical complexity (e.g., seriousness of their medical problems), in order to support my salary. If I am able to evaluate and treat more than X number of patients, then I receive a bonus to my salary based on a small proportion (~20%) of the profits recuperated by the hospital for each of these clinic or hospital visits.
Is it wrong to get paid more for increased productivity?
I understand the argument that increased productivity may indicate doctors like me are spending less time thinking about or carefully treating patients because we are rushing through the visits. Alternatively, providers may be overbilling insurance companies for falsely complex visits (e.g., claiming a patient who comes to clinic for a mild tension headache has a life-threatening intracranial problem at a high risk of imminent neurological worsening). I can assure you, as a Medical Director for my institution, that these two scenarios are extremely rare. There are far too many redundancies and quality checks built into our system which prevent us from egregiously mismanaging our patients, and the repercussions are too painful should we overbill to boost these RVUs. As an example, I treated a patient with stroke in the clinic the other day, submitted the billing for the visit, and coded the patient as having had a stroke. However, I was quickly notified by our billing department that I would likely need to correct this and therefore, reduce the medical complexity of the visit.
Who else gets productivity incentives?
My father, who coordinates shipping of agricultural products as a truck broker
My mother-in-law, who is a realtor
My brother, who prepares and packages ice cream at a local creamery
My HVAC guy, who last Tuesday recommended I replace an element in my outdoor AC condenser because it was beginning to fail
I don’t see the country up in arms about how any of these hard working, salt-of-the-earth, people are making a buck. Are productivity incentives really so bad?
QUESTION 2: Is it WRONG for doctors to receive compensation from industry?
Physician compensation is also a topic of public scrutiny due to the influence of pharmaceutical and medical device industries. Recent studies show that about 57% of U.S. doctors received some form of payment from these sectors between 2013 and 2022, totaling over $12 billion in payments. While the median payment is relatively small—around $48—a VERY, VERY SMALL number physicians receive large sums, occasionally reaching tens or hundreds of thousands of dollars, especially among certain specialties like orthopedic surgery.
I am one of those physicians. No, I have not made TENS or HUNDREDS of thousands of dollars from any medical device maker or pharmaceutical company. That is insane, and again EXTREMELY RARE. But yes, when I have been asked my opinion as to whether there is a need for a medication that would reverse the bleeding risk of commonly prescribed medicine for stroke, I am happy to give my opinion. When I have been asked, how should nurses monitor patients in an ICU for neurological worsening, I am happy to give my opinion there as well. Is my opinion valuable? Is it worth compensating me for my 15 years of experience? Sure.
But am I showing up in clinic, prescribing risky blood thinners to increase the demand for a reversal drug that I have consulted about? Am I going to the ICU and instructing nurses NOT to examine their patients so we can show patients are likely to worsen in an ICU, and therefore increase the need for better monitoring strategies? Of course not.
Certainly, we should be concerned—and this is supported by evidence—that financial relationships with industry can influence doctor behavior, such as increased prescribing of brand-name drugs, more use of products from paying companies, and even increased overall health costs. These conflicts of interest can undermine public trust and, in certain circumstances, affect the independent clinical judgment of physicians. Despite the documented existence of industry payments, the vast majority of doctors strive to base their treatment decisions on what is truly in the best interest of the patient. Moreover, hospitals mandate the reporting of financial and non-financial relationships between providers and industry to ensure all efforts are made to reduce any conflict of interest. Institutional safeguards, including disclosure requirements, are in place to help minimize the risk of undue influence, and many physicians opt out of accepting industry payments altogether. Ultimately, the goal of clinical medicine is to provide effective, evidence-based care tailored to each patient's specific needs and circumstances using shared decision making. This means considering the patient’s interests, social needs, and goals.
“Hospitals mandate the reporting of financial and non-financial relationships between providers and industry to ensure all efforts are made to reduce any conflict of interest. ”
QUESTION 3: Are vaccines a ploy?
No. There is indisputable data that present-day, FDA approved vaccines save lives and prevent disability. When COVID-19 emerged in early 2020, I watched OurWorldInData like a blood-thirsty Wall Street Financial Advisor tracking the stock market. Here are estimates reported by countries around the world for the number of deaths related to illnesses we can prevent with available and inexpensive vaccines.
Yes, hospitals and clinics receive modest payments for providing vaccinations, primarily intended to cover the cost of the vaccine and the time for administration and patient counseling. In the U.S., programs like the Vaccines for Children (VFC) program help ensure broad access. The public health benefits of vaccination are substantial; recent outbreaks of measles and other preventable diseases illustrate what can happen when immunization rates fall. Vaccines have been proven time and again to reduce hospitalizations, deaths, and healthcare costs.
Misinformation about how doctors are compensated, particularly regarding vaccines and pharmaceutical ties, can exacerbate distrust and fuel conspiracy theories. While no system is perfect, and the influence of industry requires continued oversight, the majority of U.S. physicians are motivated by a commitment to patient care. Effective public health, including vaccination programs and policies, depends on trust in this system, supported by ongoing transparency and data on actual doctor compensation and prescribing behavior.
If you have concerns about your physician’s prescribing behaviors, or feel there is a conflict of interest, there are better ways to get answers than from political officials who do not practice medicine.
Ask your physician directly if their recommendations are tied to a competing financial interest of theirs
“I know you recommended Emgality for my migraine, but do you get any kickback from Lilly or other groups for this prescription?”
Ask to speak with Patient Relations to learn more about disclosure policies for your health care providers
“I believe you want what is best for me, but I’d like to learn more about the conflict of interest and disclosure policies in the clinic. Who can I speak with about this?”
Search your hospital’s web page for published disclosure policies (many hospitals publish this information in a public manner for the sake of transparency)
Ultimately, if you have doubts about what your provider has recommended (“come back to clinic in 1 month to check in”, “let’s try tizanidine for your neck pain”, “I’ll refer you to see a spine surgeon”), ask why. We are happy to share our opinions, and we want you to buy into your health. No doctor wants patients to come back unsatisfied with their health care. Does my HVAC guy want my condenser to break down and cause me undue grief? Does my brother want to carelessly package ice cream leading to poor quality, contamination, or illness among consumers? Does my father want the soy bean delivery to be delayed in Topeka and upset the buyers in Missoula? These are bad for repeat business, and this is no different in the health care system.