Pushback On My Medicare Proposals

In response to my Wall Street Journal editorial, David Williams claims that my proposals would raise Medicare’s costs, not lower them.

I proposed to allow Medicare patients to pay market prices for walk-in clinics, doc-in-the-box clinics, surgi-centers, free standing emergency care clinics, etc. (An editor’s glitch muddied the editorial’s description of the idea a bit.) I also proposed to allow Medicare patients to pay market prices for telephone and email services, such as those offered by Teladoc.

I believe that all these outlets can accept Medicare patients right now, but most do not because Medicare’s fees are too low. Since the prices these outlets charge have been mainly determined by cash-paying patients, they are real market prices. And, since they are lower than what Medicare would have to pay at a primary care physician’s office or a hospital emergency room, I argued that Medicare would actually save money.

David’s response:

When Medicare adds services, it tends to increase costs, not reduce them. Case in point: it’s cheaper for Medicare to pay for home care than to pay for someone to be in the hospital who can’t go home and take care of himself. But add a home care benefit to Medicare and suddenly everybody opens a home care operation and finds ways to bill Medicare. Do the hospitals get less crowded? No.

He argues the same would be true of walk-in clinics, telephone consultations, etc.

Let’s suppose for a moment that David is right. What would that mean?

It would mean that under the current system a lot of seniors aren’t getting care they want because of non-price rationing, probably mainly rationing by waiting. Reduce the waiting time and make care more convenient and they would get more care. But if this is true, it is not a good feature of the current system.

I previously reported on a finding that for some Medicaid patients the time price of care is a greater deterrent than the money price of care and I speculated that this may be true for low-income people as a group. It may also be true for a lot of non-poor people.

If so, we can improve health care and improve everyone’s wellbeing if we give people a choice: let them have the opportunity to get care that is rationed be price as an alternative to rationing by waiting.

Instead of paying the full price at the Minute Clinic, for example, Medicare might pay half price and allow the patient to pay the other half. Such an option would give seniors the opportunity to pay out-of-pocket in order to economize on time as opposed, say, to long waits for free care at the emergency room.

I confess that I don’t know what the result would be, but I am sure that there is no good reason to continue with the rigidities of the current system. By experimenting, I am confident that it wouldn’t take long to find an approach that will improve care, improve the wellbeing of patients and their families and lower the taxpayer burden in the process.

David also objected to Medicare’s paying for concierge doctor services. I disagree with him there as well. But I’ll save that issue for another day.

Comments (46)

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  1. Ronald Feldman MD says:

    I am an advocate for free market medicine and am a fan of John Goodman.

    But you have it wrong when you compare cataract surgery to an office visit. The global Medicare fee for procedures and surgery includes pre-op assessment, history and physical, surgery, and post-op care. The fee is based on work (including stress), malpractice risk (surgeons pay much higher rates), and should reflect extra years in training and risk of the procedure to patients ( possible vision loss). Relative values for Medicare are imperfect, but any M.D. knows the difference between office assessment of a relatively mild illness and more advanced interventions.

  2. Greg says:

    Thanks for this clarification. I guess the WSJ doesn’t give you the space to elaborate on these things.

  3. Paul H. says:

    Very sensible. And very original thinking.

  4. Ken says:

    I agree with Paul. This is very orignial thinking. It’s what I like most about this site.

  5. H D Carroll says:

    The fact is that it may very well be that costs would go up if Medicare patients received care in a more or less free market of provider pricing, certainly initially. This is because Medicare has in all likelihood paid way to little all these years. To recognize this is the first step towards fixing the system – it is necessary to face up to the fact that Medicare has been too good a bargain for seniors, at a massive price to the rest of us through the cost shifting tax that has obfuscated real price measurement. A rational pricing structure (free but consistent to all payers, no matter who the third party association is) is the only environment where a true market balance of supply and demand, filtered through the lens of quality information to allow for the measurement of value, can occur. We cannot allow the distortion caused by a price fixing, under paying, overbearing behemoth to continue to exist and expect the problems of our so called medical expense system to go away.

  6. Devon Herrick says:

    The idea that Medicare (and especially Medicaid) rations by waiting should not come as a surprise. In the absence of price rationing, there must be another mechanism to reduce excess demand. A better system would allow seniors to control the funds that pay for their incidental medical care and have coverage for catastrophic medical needs. Then seniors themselves could decide if using a walk-in clinic, a telemedical consultation or a concierge physician holds the most value. Under those conditions, the providers of innovative medical services would compete on price, quality and convenience to attract paying customers.

  7. John Seater says:

    It seems to me there are two issues here.

    First, there is what I call the Consumers’ Union mentality that lower prices, no matter how achieved are good. The corollary is that higher prices are always bad. The view is nonsense if lower prices are achieved by the government setting those prices below the market-clearing level. When that happens, there is less of the good exchanged, and some people don’t get as much as they want because of non-price rationing. It is a standard exercise in first-year PhD micro to show that such a situation is socially suboptimal. So, suppose prices really do go up if John’s proposals are adopted. That may be a *good* thing, not a bad one, because it may be nothing more than a return to the socially optimal market equilibrium. In fact, it *will* be a good thing unless there are other distortions a work. David Williams hints that there are such distortions, arguing that everybody will move into home care and find ways to bilk (not just bill) the system. Is he just saying that the government is too hopelessly incapable of running a good program? Private medical insurance doesn’t have such problems. If government is incorrigibly incapable of administering an insurance program, perhaps we can achieve the desired end by redesigning the program, which brings me to my next point.

    Second, there is the issue of market incentives. Could we not introduce some incentives that would make it in the patient’s interest to resist improper billing? John does not talk about the nitty gritty of implementing his proposals, but what if Medicare stopped paying the providers directly and instead gave vouchers to the poor. What if those vouchers covered only a fraction (possibly dependent on the recipient’s income), so that the the recipient would have to pay part of whatever price the provider sets? That would mean the recipient in effect would have a co-payment to make, coming out of his own income. That would give him an incentive to look for low-price providers, which would introduce price competition among the providers.

    In general, I do not see anything about the health care market that is fundamentally different from any other market, other than that government at all levels has intervened and made a mess of things. As a result, it seems to me that the usual incentives should work just as well in the health care market as in, say, the market for personal computers, automobiles, or food.

  8. Neil H. says:

    Good response to Williams.

  9. Linda Gorman says:

    Maybe the pushback means that the forces of darkness have realized that they can’t marginalize you as a fringe element much longer and that they will finally have to read and respond to what you are writing.

    I thought yesterday’s article was a good summary of what you’ve been saying all along. (The joke in our household is that Goodman figured out the solution in Patient Power. Reform is just a matter of saying the same thing over, and over, and over for several decades so that people come to believe it. Therefore there is a good reason why I’m such a boring conversationalist at the dinner table so stop complaining!

    If you need an immediate example of how what you propose can reduce Medicare expenditures you might consider the flu shot example from this blog post from last year. Medicare could save a quarter of a billion just by sending every beneficiary a $20 gift card for a flu shot at urgent care clinics.


  10. Bob Barry says:

    My wife and I choose Medicare Advantage with high deductible. Now, we’d go for an even-higher-deductible and/or an even-higher-copay if a plan paid us cash every month, perhaps into a ‘health savings account.’ This would be the polar opposite of the present all-we-can-eat Medicare + Medigap model. The actuarial equivalent pricing would be fine, so we would not be a net-cost to the system. I’m sure we’d be a net savings to the system. No frivolous use, money saved up for that rainy day.
    Bob Barry

  11. Al says:

    John, I am glad you asked for comments because I previously read the original editorial and had a question though perhaps there was some clarification in this blog. You said ” If patients and doctors are willing, Medicare should be willing ******to throw its 7,500-item price list away******, pay some portion of the concierge fee,”

    That $1,500 concierge fee seems to refer to the VIP concierge system where additional payments are collected from the insurers (perhaps you assumed it was the total fee collected?). A concierge does what an Internist is supposed to do in the first place, but is impeded in doing so by the bureaucracy imposing price controls and limitations on contracts. Thus I would like to have a clarification regarding your thoughts on concierge medicine since in the editorial it appeared that you might have been thinking of placing a global fee onto the Internist to reduce exposure to further costs. If that is the case then you might be creating a dangerous scenario with similar results to those seen in HMO’s. Moreover, the use of a concierge does not necessarily equate to a reduced use of sub-specialists such as cardiologists unless a global fee is being applied.

    I agree that part of the dilemma you seem to state here and elsewhere which involves price fixing by government. The solution not alluded to in the editorial but perhaps is alluded to here is to remove the ban on balance billing even if that ban has some restrictions or reductions of payments (as you seem to mention here).

  12. Kurt R. Solem, MD, FACEP says:

    Dear Mr Goodman,

    I agree we need to take on Medicare financing but your 3 simple ways are based on faulty premises. I happen to notice you do not have listed any MDs on your Board.

    The cost of a cataract procedure does not translate to profit any more than the cost of a can of beans does for the grocery store. You did not at consider the cost of the procedure for the physician. An office visit to a primary care is relatively inexpensive for the physician and the cost to the physician doing the cataract procedure is relatively more expensive…malpractice, equipment etc.

    The Concierge concept is excellent however the patients pay $1500 out of their own pocket in addition to the costs the physician charges medicare. Only the well-to-do can afford this. This may or may not save medicare charges, I do not believe it has been proven one way or the other, The concept of market place prices is excellent, but remember you get what you pay for. Considering the medicare population, I do not think you are going to achieve the same or even the minimum standard of care during a telemedicine visit juxtaposed what a personal visit will give you. When I go out for a special evening with my wife, I dare not go to a fast food restaurant.


    Kurt R. Solem, MD, FACEP

  13. David E. Williams of the Health Business Blog says:

    Glad my post sparked a response. Don’t get me wrong. As an entrepreneur with an MBA and econ degree and a blog about the business of health care I’m a big fan of the free market! Much as I would like free market principles to apply directly in the health care space, a lot of the comments above are wishful thinking.

    In my view commenters are putting insufficient weight on the supply side of the equation. Consumers don’t spend their time dreaming up demand for emergency clinics, telephone consultations, home care, etc. But there are plenty of providers out there working very hard to find ways to generate referrals and bill Medicare and private payers in the maximally profitable way for just such services. They are not simply responding to consumer demand.

    You can’t credibly claim your proposals are going to be cost effective unless you consider price X volume, not just price.

  14. Al says:

    Kurt, as an Emergency physician telemedicine might not fit in too well, but for those treating chronic diseases that are well known to their physicians telemedicine if managed correctly (by the patient and physician) might offer additional treatment mechanisms that have the potential to increase quality and reduce costs. Think diabetes and chronic congestive heart failure.

  15. Buster says:

    If used appropriately, maybe telemedicine could keep some business away from the emergency room.

  16. Eric says:

    I don’t really have anything to add here, but conversations like this one is why I read this blog (even if I don’t agree with everything that is written).

  17. Brant S. Mittler, M.D., J.D. says:


    Excellent editorial as is your longer paper with even more ideas for reform.
    But, I wish you had criticized Medicare Advantage HMOs, which are even more expensive than fee for service care and provide no added quality – only advertising hype about coordination of care and choice which is completely bogus.

    Also, one reason that the free standing clinics use protocols and guidelines is because they fear lawsuits. If we really got the kind of whole scale tort reform that conservatives want, these quality measures would rapidly disappear. The fear of being sued puts a brake on the business ethic of maximizing profits without being sued.


  18. John C. Greene, CLTC says:

    Personally, I like many of your ideas. Clearing what we are doing isn’t working. The Stark rules don’t work in a modern economy, they were developed for a different problem in a different time and have outlived whatever usefulness or purpose for which they were intended. I would note, and you might want to consider, that everyone’s favorite “fraud and abuse” argument is actually perfect here. In a market economy where seniors might control the dollars, it would reduce the potential for fraud and abuse because you reduce the way in which transactions occur which may be part of your point, but could be made more overtly.

    All the best,
    John C. Greene, CLTC

  19. Devon Herrick says:

    @ David
    The current system has perverse incentives on the demand side that leads to overutilization. However, we will never reform health care until we also reform the perverse incentives on the supply side. Seniors need to control more of their own dollars and to the extend they do, providers will have less opportunity to bilk Medicare. The clinic wouldn’t care whether a customer was on Medicare, BlueCross or uninsured. But the clinics need to be free to rebundle and repackage services in ways that appeal to consumers. Only then will you have providers competing on price and quality.

  20. Steve Wemple says:

    Excellent way of also describing why we don’t want government in charge of any more of our lives than absolutely necessary as they will complicate and screw it up.

  21. Joe Fox says:

    I work for a large orthpaedic group in East Tennessee, who tried to help area hospitals lower the cost of implants by forming a physician owned implant distribution company that negotiated a 25% reduction in implant cost to the hospitals. I am attaching an executive summary of the business model, that saved the pilot hospital $600,000 the first year in total knee and total hip implant costs. Several large device manufacturers have been actively trying to stop ours and other similar models from operating by filing complaints with the government and lobbying polititians to help make it illegal for physicians to partner with hospitals to control costs. That being said, your comments are right on target concerning the Stark Law restrictions and to some extent the some parts of the Anti-kickback statute.

  22. Larry Wedekind says:

    Dr Mittler: I am in the forefront of providing care to Medicare Advantage members through an Integrated Delivery Network of physicians (IDN) that my company manages. My company manages over 20,000 Medicare members in different networks and states. It is regrettable that your personal experience with Medicare Advantage was not positive. However, I can tell you unequivocally that this system works for the members and the physician providers when the Medicare Advantage Plan (HMO) contracts for the Care Management of their members with an IDN like ours!

    First of all, Medicare Advantage Plans, by definition, must provide much richer and better benefits to the members with much lower out of pocket costs in order to get a CMS contract. Second, the physicians must be at risk through their IDN and must abide by established Pay For Quality criteria in order to receive quality related bonuses. Third, a Hospitalist system must be in place to manage the members properly when they are hospitalized, and Fourth, Nurse Practitioners must be used to do Health Risk Assessments in the member’s homes or in the physician offices when the PCP’s are too busy or the members have not established a Medical Home. The establishment of a true patient-centered Medical Home is the most critical factor in reducing costs within the Medicare and Medicaid system. We work with members and physicians to do this and we do it most effectively. Our typical MLR’s are below 70% with all of our Medicare Advantage Plan (HMO) partners and our physicians who comply with our P4Q’s make substantial bonuses and spend a lot more time with our members as a result. Our members do not need or frequent the ER or the hospital nearly as much as the traditional Medicare patients in our markets.

    The pairing of an HMO with an IDN is the answer to our Medicare system woes as long as the Savings that result are shared with the taxpayers. I have shared this system approach and the inherent benefits with John Goodman and am hoping that he will put his great mind to bear on this strategy.

  23. Larry Wedekind says:

    John, are you aware that certain Medicare Advantage HMO’s are giving Part B premium monies back to their members through their Social Security checks just for using their system and establishing a Medical Home? This is akin to your suggestion that CMS should reward members for saving the system money through good Care choices.

    One more thing, it is vitally important that your consumer empowerment initiatives like HSA’s become enabled through legislation at the national level for the benefit of seniors enrolled in Medicare. If a separate “Senior HSA” initiative is allowed when adults reach the age of 25 and can only be used for out of pocket costs under Medicare, then the entire system will be more consumer driven and this development alone will drive down costs within the system. This Senior HSA intiative, combined with IDN’s as described above, will save the system financially and improve our healthcare quality.

  24. jerry harrison says:


    you did not include in these comments HSA’s. Nor do you address some smaller employers exploring self-insured health plans focusing on prevention and fitness.

    Is there some good reason for not including these concepts? It is my impression there is sufficient anecdotal evidence these work to advocate a larger role for these approaches.

  25. Karl says:

    To compare an office visit for a minor medical evaluation to cataract removal is so off base you have lost credibility. Would you rather have your ophthamologist struggle for an hour with a cataract extraction in an effort to to warrant their reimbursement. Probably not. As a plastic surgeon I no longer perform complex microvascular reconstruction on medicare patients because of their reimbursement fee schedule. Procedure such as these often times require operating room times in the 8-10 hour range and prolonged hospital courses. Reimbursements do not even cover office expenses for a day for such procedures. When considering cases such as these, on the balance you are better off being in primary care seeing 20 medicare patients in a day and not having to loose the sleep.

  26. Jerry says:

    My Medicare waste experience. In the last year of his life, my father had pulmonary issues. He aked his MD if he would qualify for an “electric scooter”.
    MD says sure and fills out a form. I call the local supplier and he tells me that the scooter is $1800 but medicare would not pay anything toward the purchase. However, he says – you qualify for a moterized wheel chair – and medicare will pay 80% of the $6,000 cost and Pa’s supplementry insurance would pay the rest. The chair was delivered that afternoon.

    Pa passes on a couple of months later. I call the chair supplier about what to do about the $6,000 Chair that has had maybe 2 hours of use.

    He tells me it’s mine to keep. He says I can try to sell it myself. He tells me he will pay me $400 for the unit – he says he has two used ones in his showroom at $800 and that there is no market for used ones because anybody whose MD says they need one will get a new one. I think the supplier was honest and simply was following the rules. We gave the unit to a work assocites mother.

  27. ralph says:

    @Devon, you are exactly right, only an actuary can understand this steerage. With the new 80% MLR, there will be even more incentive to drive up consumption

  28. John Goodman says:

    @ All who complained about my comparison of the two physicians, I hear you. Only the market can get the two prices right.

    @ Al and Dr. Solem

    The kind of concierge service I am thinking about is one that provides all primary care for a fixed monthly fee.

    @ David Williams

    I think I answered you in the text of my post.

    @ Brandt Mittler

    All Medicare HMOs are not alike. I have a post on this on Monday. In the meantime, see Larry Wedekind’s comments.

    @ Joe Fox

    I agree with you on the Stark Amendment.

    @ Jerry Harrison

    I have not forgotten about HSAs for seniors. They are addressed in other writings. For example here:

  29. Bob Deuell, M.D. says:

    My Ophthalmologist tells me he could teach anyone to do a cataract removal in 30 days. We do pay too much for certain procedures. Look at the pay differential between specialities. We pay too much for procedures and not enough for cognitive care. An Opthalmologist has a total of 13 years education including college. A family doctor has 11. Is that worth the difference of seven fold? I think not.

    Your suggestion of letting the marketplace prevail is correct, but use of independent clinics using mid-level providers will not work to lower costs and encourages uncoordinated care which is not efficient. Studies show in states where that is allowed those mid-levels refer more and order more tests because of their lower level of training. (A form of defensive medicine.). Patients need a medical home with a fully educated and trained physician who
    can delegate or consult with a mid-level provider that is under direct supervision of that

  30. Kenneth A. Fisher, M.D. says:

    Price fixing and central planning has repeatedly been a failure throughout the world; market forces must determine the value of each aspect of medical care. Trying to fix Medicare/Medicaid is like building a castle in quicksand, it is doomed to fail.

    Health Savings Accounts (HSA), accumulating tax free starting at an early age, funded in large part by a tax credit for those paying income tax and a reverse tax for those not paying income taxes; the unused portion of those who paid with tax credits can be passed on to their heirs after being taxed. Expensive items would be covered by high deductable insurance that would be federally subsidized for the poor. This would meet the need for every generation to pay for its own benefits. Market forces and professional peer review would control costs, insure quality and protect against legal action. This would replace Medicare & Medicaid after an appropriate run in period.

  31. Brant Mittler says:

    @Larry Wedekind:

    Larry, it sounds like you are doing a heroic effort to make a bad plan work. Medicare HMOs would not exist without a taxpayer handout. They are products of the government’s rewarding big political contributors and also satisfying the Robert Wood Johnson Foundation idealogues who always know the right way to practice medicine. The insurance companies have all the money and power in the world and they help run Congress. Medicare HMOs have been shown to do little but make money for their sponsors since the first Mathematica study commissioned by HCFA in the late 1990s. They had to be labled +Choice and Advantage to gull the public. I also have the advantage of having seen a lot of documents as both an expert witness and then a practicing litigator suing HMOs for their negligent acts which led to a lot of patient suffering and some deaths. Just look at the documents and see the results. Medicare HMOs lead a charmed existence because federal prosecutors turn a blind eye to fraud and misrepresentation. But fraud is always hard to prove. And politicians love the contributions from their sponsors. And Conservative Republican judges are ready to apply federal pre-emption arguments to protect HMOs.
    Suddenly doctors taking care of patients with market forces at work has become doctors working for groups with contracts with HMOs and hospitalists signing out to each other usually miscommunicating the transfers every 12 hours so the hospitalists can get proper rest and nurse pratitioners making home visits to do what the hospitalists and PCPs can’t figure out all supported by legions of well-intentioned office support staff and health care attorneys enabling this whole mad enterprise. Sounds a pretty complex and expensive way to take care of sick patients. Or well patients who you keep from getting sick and visiting the ER. Maybe it will save money. I’m skeptical. Sounds likes it’s out of the ObamaCare 2000 page playbook. But I do pledge allegiance to the new medical team. That’s part of being a modern. The “cloud” knows the patient. And I get nervous when doctors are put at financial “risk.” What kind of “risk” does that put patients at?

  32. Al says:

    Larry Wedekind: ” I am in the forefront of providing care to Medicare Advantage members…”

    If Medicare Advantage is so good why is the per capita rate paid to those programs more then is paid per capita for traditional Medicare?

    Maybe Medicare Advantage is only a sham.

  33. Larry Wedekind says:

    Brant: Let’s talk about the Team Medical concept. IntegraNet has a Medicare Advantage liver transplant patient who one of our Nurse Practitioners visited today in his home and met with him and his family. Her visit accomplished an amazing amount of good and provided concrete information to him and his family that will improve his opportunity to get his new liver. All part of our Medical Home philosophy and methodology – and our Medical Team concept in support of his physicians. The sooner he can receive his new liver, the better his health will be and the lower his costs will be to our system. The longer it takes, the worse he will get and the drain on our healthcare system and on us will be huge. Our Medical Home strategies do actually improve our patient’s health and outcomes! This significantly lowers the cost to the system itself.

    To address Al’s comment, you are right! The global capitation premium paid to Medicare Advantage plans is higher. Why? Because this extra premium pays for many extra and costly health benefits (like vision, hearing, fitness club, and dental benefits, to name a few) and it pays for lower out of pocket costs to the beneficiaries. Despite Pres Obama’s claims that the Health Plans are keeping the extra premiums as profits, the exact reverse is true. The Health Plans really do not benefit finanically from these extra premiums. The patients do. However, in the PPACA (Obamacare), this extra premium is being eliminated. Thus, the extra premium that is helping to improve outcomes and lowering costs will soon be gone. The government should instead be focused on sharing the profits generated by the Health Plans in the manner that I suggested above in my previous Comment. The private sector has always and will always be the answer to our entitlement program financial woes.

    Remember that there is NO management at all in traditional Medicare. Hence the very high amount of fraud and misrepresentation and the resultant out of control costs. The management and care coordination services offerred by Integrated Physician Delivery Networks (IDN’s) greatly reduce fraud and misrepresentation and improve patient outcomes; thus reducing the overall cost of care.

  34. Al says:

    Larry W. writes: “The Health Plans really do not benefit finanically from these extra premiums. ”

    The exact same thing was said about the HMO system the last time around. Later it was found out they were wrong so I would say that once again the system is being gamed until it can be proven otherwise. Perhaps we should withhold 50% of everyone’s salary to repay the government if the proof is not forthcoming.

    As far as quality goes you are repeating what was said about HMO’s the first time around as well, but we can encapsulate everything in Ware’s famous conclusion “During the study period, elderly and poor chronically ill patients had worse physical health outcomes in HMOs than in FFS systems”. I think we will find the same thing with regard to Medicare Advantage.

    If Medicare Advantage is so good then get rid of the extra payments it is given and when they fail a patient in their system let them pay for the problems not traditional Medicare.

  35. Brant Mittler says:

    If you don’t think that Medicare HMOs make alot of money and actually benefitted from ObamaCare, look at the “free market” which you all plege allegiance to, namely the stock market. Pardon my cynicism. Look at Humana’s stock price from the day ObamaCare passed to the present. It’s steadly climbing upward – compliments of your and my tax dollars. And why shouldn’t fee for service patients get health club membership, vision care, dental care, and whatever else the K street lobbyists have garnered for their HMO clients? What is so special about HMOs that they get more money for doing more? Is that the “free maket” at work? They were supposed to get more money for doing less (unecessary care).

  36. Paul Petelin MD says:

    To Bob Deuell MD,

    I would love for you to forward to me the name or better yet to post the name of your Ophthalmologist buddy who said he can teach you cataract surgery in 30 days. There is a very wide range of mastery in cataract surgery worldwide, you really must be something special, or he must be something special, or both

    Its nonsense ignorant statements by non-combatant “coulda done’s” like you that muddy already muddy waters.

    I guess all third year Ophthalmology residents this year can pretty much quit August 1st after 30 days.

  37. Bob Deuell, M.D. says:

    Dr. Petelin,

    You miss the point. No, I don’t think Opthalmology residents should stop after 3 years. There is much more to Opthalmology than doing cataracts. I appreciate that, but that does not change the fact the system overpays for procedures in numerous specialities and underpays for cognitive care.

    Not sure what the “non-combatant ‘coulda dones’ ” comment is about since you do not know my background. FYI. Board Certified 25 years in Family Medicine. (Did full Ob for years.). Four years in Public Health Service. Nine years in Texas Senate. Sorry you’re so angry.

  38. Paul Petelin MD says:

    Bob, your right I’m angry, whats not be angry about. We have a system that’s completely broken, we have a joke of a president parading around a few FP’s with the blessing of the “AMA” claiming we are all on board, and we have services that are already wildly undervalued being blamed for where we are currently.

    On top of that we have irresponsible statements by people like you that add nothing to the debate and just pit us against ourselves. You are trying to add value to what you do by trivializing and way oversimplifying something as well established as cataract surgery and you just acknowledged that. We have an author who runs this blog and gets a national audience and then makes a woefully flawed comparison that gives the perception that eye surgeons “rake it in” because we get $500 to take out a cataract, using in his comparison only the act of taking out the cataract. Its infuriating actually. These are supposed to be our brightest people.

    Jury of non-combatants is just that. People like you and Goodman who stay out of the line of fire and sit from the comfort of the sidelines and critique and say how easy that is, and I can do that or I could have done that, or in your case I used to do that etc etc… Fact remains that surgery requires much more diligence, risk, toughness, anxiety than parking in clinic all day. I don’t know how any surgeon in this country would ever do a whipple for $1100 and then watch as all the primary services including FP and internal medicine come daily to the bedside, get to charge for each inpatient visit to manage some meds for the next three weeks and walk away making twice from the case what the surgeon did. If that is not broken than I don’t know what is.

  39. Bob Deuell, M.D. says:

    Dr. Petelin,

    You still don’t get the point. FYI, I have defended your specialty multiple times in the legislature and elsewhere. I agree with you about Obama, but would remind you AMA is a surgical dominated organization. (I am not a member). Your perceptions of my not being in the line of fire or irresponsible are wrong. What is irresponsible about pointing out inequities in the system? It is actually that experience in the trenches that have formed those opinions that are based on facts and observations. I have high regard the the surgical specialties, but fair is fair. Medicare and Medicaid fees were set in 1965 by three surgeons. Fees have gone up, but very little has been done regarding specialty differentials. You obviously do not appreciate primary care, office based or otherwise. Perhaps I should elaborate on the multiple times I have had to care for surgical patients
    after the procedure. We have a saying in Texas; “I can explain it, but I can’t make you understand it.”. Regards.

    to you, but I can’t make you understand it.”.

  40. Paul Petelin MD says:

    No I get the point entirely I just can’t seem to get you come out and say what you really believe and that is that the services we all provide are all equal in value. By your math and John Goodman’s math then my entire morning of surgery this morning, of whihch I do twice a month, was worth about $2000 given my efficiency in doing it. the lasers i’ll do this afternoon about $5 each. I am not the only one that has a problem with that.

    Goodman’s article specifically attacked cataract surgery and its relative value and you responded with an equally pointless comment that would not stand up to peer review. I objected, invited a discussion specific to the comparisons in his article, invited your Ophthalmologist to chime in as well. All you have done since then is backtracked and suggested that I misunderstood you, you are in fact my advocate.

    I am not the one pinned down in a value trap. Cataract surgery or any of the other services that I am fortunate to provide have value that is routinely gauged by the free market. If Goodman had done any work getting ready for his WSJ piece among other things he would have discovered there is an interesting phenomena taking place that makes cataract surgery a wonderful case study of his ideas. The boomer generation is not waiting for their cataracts to reach medical necessity. They know what we are capable of doing for them and they are stepping up in increasing numbers to have surgery electively and appropriately at their expense 8-10 years early. Can you give me a similar example in your practice where people pay out of pocket to have something done that would be covered for them eventually if they just wait for it?

    “Fair is fair ?” life is not fair. Your challenge is not my challenge. You need to find ways to add value to the services you provide and I am as poorly equiped to tell you how to go about that as you are telling me what my services are worth. One thing I do know is that dumming down what any physician does, you included, into only a time component is about as close to medical marxism as I can imagine and not the direction things need to go.

    Not once BTW did I say I do not value the work of any of my peers in any area of medicine or suggest that any of them are overpaid as you have. And you must be kidding about the AMA, they look out only for themselves and protecting their precious CPT revenue, the bain of our exiestence.

  41. eyepatient says:

    I am a little behind on posting here, but only recenly heard about Goodman’s comparison of a primary care visit to a “10-15 minute cataract surgery.” I am a patient of an ophthalmologist in KY. Yep, that’s the state that recently allows optometrists to do surgery:( My cataract surgery was the most life altering procedure that I’ve ever had. Nothing can compare in terms of my outlook on life and improvement in my daily activities. I talked to my doctor about your WSJ article, and he said that the surgery fee in KY is closer to $700, and it includes 90 days of free care, which, at the minimum, is three 15 minute office visits. So that’s more like an hour or more of his time. This is not mentioning the thousands of dollars of equipment he had to buy to perform the exams, the liability insurance that he has to buy, and learning the current microsurgical skill. There is simply no comparison. Saying that the market is paying 15 times too much is absurd and it hurts your credibility. I would assert that the cost of a cataract is far less than the office visit in terms of net revenue for the doctor. In fact, my doctor pointed out that the net profit has dropped so low that selling a pair of glases is more profitable. It’s folks like you and the the short-sighted folks in our government that think a top-down approach to cost control is in order. You are simply wrong here, your analysis hurts seniors, and there is no two ways about it. When you need cataract surgery one day, you’ll see what I mean. Hopefully, there still will be people doing it then.

  42. Paul Petelin MD says:

    Thanks eyepatient for sharing. Perhaps you could share with the group what the value to you was in a monetary sense, what you think you would feel was fair if you were footing the bill considering what you received in terms of time with your doctor in KY and the value to you of the results of surgery, as if you had a fixed amount of Medicare dollars to spend on yourself in your later years that you were in complete control of. Keep it conservative and don’t count the wonderful value of likely having ditched whatever glasses you needed before surgery, Medicare doesn’t count it either. Perhaps the biggest free gift in the history of medicine.

    It no surprise at all, reading the postings of the good Senator from Texas Dr. Deuell that the bill in KY passed, he’d be considered an expert on the topic and we all know how he feels. It seems even within the medical profession nothing much is sacred, no privilege is sacred or earned, if the price is right it can be bought politically just like anything else these days. Sad thing is only the Ophthalmologists in KY and scores of unfortunate patients that you will likely never hear much about will be the ones that feel the brunt of it. Hardly even made the national news.

  43. Al says:

    The issue should not be which specialty is paid too much rather how and for what doctors are paid. That generally is left up to the market, but in the case of Medicare a bunch of bureaucrats make that decision. There is no doubt that there are inequities of payment regarding the different specialties, but that doesn’t mean that anyone physician is being paid appropriately.

    I got the following from Dorsey. JAMA, Vol 290(9).Sept 3, 2003.1174. It is not recent, but it gave some additional data that is important to note. Anyone can look up the more recent compensation data. I enclose the data that regards the fees of ophthalmologists and internists.

    Ophthalmology: Lifestyle, controllable; average income, $225,000; work hours per week, 47; years of required graduate medical education, 4

    Internal medicine: Lifestyle, uncontrollable; average income, $158,000; work hours per week, 57; years of required graduate medical education, 3

  44. Paul Petelin MD says:

    In the middle of clinic today, just had a one year cataract patient ask me why VPI (vetinary pet insurace) just paid the vetinary Ophthalmologist $2200 to remove a cataract from her 8 year old lab. She pays $79 /month for coverage. She went back to her EOB from her insurance company and was “horrified” by what we were reimbursed…… “I never knew”….

    Is it true it is safer and more lucrative to provide cataract surgery to dogs than to humans? Any of the brave earlier posters care to comment, Goodman ??

  45. eyepatient says:

    I’ve been asked a hard question and again, late in responding. If the free market says $2200 for the dog cataract and considering the dog probably doesn’t see as well as I do afterwards (no way to check), I’d say I’d pay at least $2200 for the cataract surgery. I’ll say it again, our government is trying this top-down approach to cost savings without tackling the bigger issues, like people are living longer, medicine is getting more expensive, and medical care is getting getting more costly to deliver–look at the equipment you have to buy. 2000 pages of Obamacare crap probably doesn’t help. The free-market may not be the answer either. Imagine what a doctor may charge for a life-saving procedure? I’d be scared to think. There’s got to be a balance in between. BTW. The optometrists in KY decided that a 32 hour weekend course was adequate training for surgery.

  46. ralph says:

    Actually, the free market does not work, and poeple are saving money every day at MediBid.com. It’s price fixing that does not work