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Another Doctor E-mail

Thursday, December 3, 2009  |  posted by Hugh Hewitt

Hi Hugh,

I’m an Internal Medicine sub-specialist in Infectious Diseases retired from Academic Medicine, now in medical publishing (at the rip ole age of early 40’s). I have been listening to your show each evening. Thank you for focusing exclusively on health care reform. My upfront disclaimer on what I’ve “done to fix things”: I have contributed to Docs4patientcare, but I have gone above & beyond the call of duty by announcing on my Facebook that you are doing an excellent job with your interviews, and telling everybody to listen to your show. Yay for me.

You have done well so far in airing the current problems that physicians have with Medicare (& Medicaid) reimbursements. One of your surgeon callers adequately described that an in-house level III consult is worth $70 (of which overhead & taxes take ?), and few physicians can be motivated to get up at 2 a.m. & drive to the hospital, stay for half the night, for roughly $35, no matter how altruistic.

To play devil’s advocate, I’d like to point out what my liberal non-physician friends say when the cuts in reimbursements are discussed: “Well, if your income of $185K goes down to $150K, then you’re still making $80K more than I am, so I think you can survive…” (From a strictly philosophical position, there are so many things wrong with this statement that I don’t know where to begin.) But, let’s focus on the pragmatic. Average Joe doesn’t understand the debt to income ratio incurred by physicians (with debt taking many forms, not only financial). And society has done a great job of stigmatizing physicians as being money-grubbing entrepreneurs who don’t give a damn about patients, such that Average Joe actually feels almost liberated when reimbursements are cut.

I want to point out that current medical students today incur more than $125,000 for 4 years of med school (if they go to a cheap state school). This figure does not include college. The repayment schedule for my debt ($100K, because I graduated in the 1990’s) is $700/month and extends until I’m 65 years old. As a subspecialist physician, I trained for 14 years to do what I do (4 college 4 med school 4 med/peds residency 2 fellowship). While my friends and neighbors were becoming teachers and loan officers and hair stylists and restaurateurs and claims adjusters, I was going to school learning how to take care of old folks, babies, and AIDS patients. Not only did I incur debt, but concurrently, I deferred income for almost a decade. So, while my friends were buying homes and having babies, again, I was learning to take care of AIDS patients.

All of this was my choice, and I do not regret that choice. But let me be clear: medical students will not continue to make these sacrifices for peanuts. They will not. And the Americans who now sit idly by, watching politicians abscond with their health care-all for ideology, will one day wake up to a health care system run by nurse practitioners & physician assistants because they are cheap. And I don’t say that to disparage NPs & PAs. But a Master’s degree does not rival 14 years of training to understand complex disease. And If you’ve got bacteria growing in your blood or you’re having a heart attack, you don’t want “adequate” care. You want fantastic care-that only 14 years of training gets you. In no other profession-not teaching, not law enforcement, not journalism-are people expected to make these kinds of sacrifices-financial, familial, emotional, intellectual. No other profession. If you want future doctors, you’d better invest in them, because no person is going to go through all this for minimal salary. They’d be stupid to do that. And medical students might be a lot of things, but they aren’t stupid.

Thank you for calling attention to these matters,


PS: as one final shocker, I’d like to tell you the salary I had a subspecialty trained Academic ID doc. As Assist Professor, my salary was $90,000/year, for which I was expected to teach, conduct research, & provide patient care. I worked 80-100 hrs/week. My NP who was employed at my HIV clinic, who worked 3 full days/week, was salaried at $80,000.

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Update on Obamacare in the Senate

Wednesday, December 2, 2009  |  posted by Hugh Hewitt

Opposed to Obamacare? Don’t forget to visit and contribute at

Arizona’s Jon Kyl joined me on today’s program to update us on the debate in the Senate. The transcript of that conversation will be here later. Obamacare can be defeated, but the huge majority of Americans who oppose the bill have to act on that opposition, not just grumble about the Democrats. Contribute, and call 202-224-3121 and tell a senator to stop, especially Arkansas’ Blanche Lincoln, Indiana’s Evan Bayh, and Nebraska’s Ben Nelson.

This e-mail arrived from an Oregon surgeon:

Dear Hugh,

I am a Portland, Oregon general surgeon, and have been in practice for about 20 years. I have listened to your interviews with Obamacare-supporting “experts” and have been struck by their evasiveness or apparent ignorance about the practical effects of past Medicare and Medicaid funding decisions, and the likely effects to come if the current proposals pass.

One of the striking shared views is that 1) yes, current law mandates a 25% reduction in fees paid to physicians, and 2) Congress won’t really enforce that law, so physicians don’t have anything to worry about.
They fail to acknowledge the past practice of “budget neutrality” on the part of CMS by drastically reducing the reimbursement of some of the most common procedures, while increasing other fees – thereby pitting proceduralists (surgeons like me) against primary care doctors.

I suggest the following questions of such experts to assess their true grasp of the situation:

1. What has happened in recent years to the Medicare reimbursement for coronary artery bypass procedures, aortic aneurysm repairs, hernia repairs, emergency gallbladder surgeries (hint: they all have been reduced by more than 50%).
2. How much does Medicare pay a surgeon to save someone’s life by performing a lower leg amputation?
a. $30,000 or $40,000 or $50,000 (President Obama’s answer)
b. $862 (The actual amount paid for the procedure and for 3 months of post-op care)
3. Compared to commercial (non-government) insurance, how much does Medicare pay for any given procedure (Answer: less than half).
4. How much does Medicaid pay (Answer: even worse, less than 40%).
5. What do they anticipate the “public option” fee structure will look like — closer to current commercial rates or more like Medicare or Medicaid (Hint: the government has never paid doctors or hospitals anything close to the going rate).
6. Given the incentives built into both the Pelosi and Reid plans to do so, how many people will be dumped from their current private insurance plans into the expanded pools of Medicare, Medicaid and the public option insurance.
7. Given the resultant dramatic decrease in practice income, how many physicians do they think will opt for early retirement or change in occupation?

8. All 3 guests I listened to mentioned the billions of dollars that will be saved by “increasing productivity.” What exactly are they talking about. Productivity is work unit per hour. So, am I expected to see more patients per hour, operate faster (I’m already one of the fastest surgeons in Oregon) or just see more patients by working longer hours. Sorry, I already work 60 hours per week, including emergency operations at 2:00 am — I’m not gonna work any harder for government rates.
9. Maybe they mean increased productivity by use of electronic medical records and electronic information systems. But most practices in our area already use those, so counting on cost reduction by future implementation of procedures that are already in use isn’t really fair, is it?

Just a few thoughts, maybe some that you hadn’t thought of.

Thanks for your focus on this issue!

Sincerely yours,
RH, M.D.

Did They Send Their Members To

Wednesday, December 2, 2009  |  posted by Hugh Hewitt

The California Medical Association announced today –a year into the debate– that it opposes Obamacare.

Great work to the CMA staff who have waiting until the last moment to figure out what their membership clearly believes.

Now, what is CMA going to do to stop the bill that will destroy most of their members’ practices and harm patients? and 202-224-3121

Wednesday, December 2, 2009  |  posted by Hugh Hewitt

Senate Democrats are putting on a brave face and putting out the word that a deal on Obamacre will come together.

Perhaps, but that is what Harry Reid has to say and what his colleagues must put out if they are going to maintain momentum. Opponents have to double and triple their efforts to let the key Democrats –Blanche Lincoln of Arkansas, Evan Bayh of Indiana, Ben Nelson of Nebraska– know that the country realizes that their votes are the ones that will decide whether American medicine is sent over the cliff. Call them at 202-224-3121 and urge that this version of Obamacare be shelved and real reform begun, an effort that doesn’t attempt to pay for insuring the uninsured on the backs of seniors and doctors.

The best way of massaging the political consequences of Obamacare is with a contribution to If Obamacare does escape the Senate it will have to return to the House where the switch of three Democrats from “yes” to “no” will scuttle the bill. has identified the 24 Democrats who voted yes and who are most vulnerable in 2010, and is raising money to give to the Republican nominees in those districts. Contributing to that fund sends a message to every Democrat in the House and the Senate that the political cost to passing Obamacare will include their jobs.

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