Letter: Lobbying Has Changed The Way Doctors Are Paid

Andrew W. writes:

I am a physician and avid planet money listener. I have been interested in your recent shows covering health care including your recent episode about fee for service medicine. You guys have touched on, but not really fleshed out, an interesting and important consequence of the fee-for-service and RVU system: all of that lobbying you talked about had significant results. Certain types of doctors are now paid vastly more than others. The discrepancies do not correlate with degree of expertise, amount of education/training (which varies for different sub-specialties), complexity of decision making, degree of illness of patients.

Rather, it is driven by the fact that 1) certain things are easier than others to measure (ie "procedures" as opposed to decision-making) and 2) certain sub specialties apparently had better lobbyists than others (so a colonoscopy is really well reimbursed while a similar procedure called a bronchoscopy is not). This in practice means that specialties that are procedure-oriented are more lucrative. Hence, a dermatologist can make a ton of money by doing many small biopsies in his or her office every day. These are easy, very low risk, arguably unnecessary in many cases, and quite lucrative. Similarly, other specialties such as radiology (especially interventional radiology), ophthalmology, cardiology (especially electrophysiology and interventional cardiology), and a variety of others are extremely well-paid while others, which are arguably more important to patients-at-large and just as difficult (such as primary care) are generally poorly reimbursed.

There are incentives to do procedures and the incentives are largely set by medicare reimbursement levels and therefore political. This system really needs to change to correct these incentives if we want to fix health care.

I'm pulmonary/critical care, for the record.