October 1997 Bulletin

Not 'elitist' plot

I have read with interest a letter submitted by John W. Thompson, MD, of Portland, Ore. (July Bulletin). He complained that too many orthopaedists put their "financial status above the interest of the patients." He could not understand how further cutbacks in reimbursement could possibly affect "top quality" care for Medicare patients. He went on to state that most of the orthopaedists he knows make more than anybody else and that our attempts to maintain our incomes is an "elitist" plot. He was amazed that a neurosurgeon had the nerve to charge $11,000 for a recurrent disk.

In America, we like to think that the marketplace determines the price of things, and much of our government bureaucracy is devoted to making sure that no one interferes with that process. We presume that the reason orthopaedists do pretty well relative to the average rank and file doctor is that we have to go to school longer to do specialized things other docs seem disinclined to do, particularly at the inconvenient times when they're generally required and at the risk of malpractice to which they are exposed.

A single orthopaedist should be able to serve a population of 17,000-20,000 (although this doesn't account for specialization such as hand surgery or pediatric orthopaedics, or whether or not they should be confined to an academic center). Basic economic logic predicts that if we had fewer orthopaedists, the price of their services should go up - yet Dr. Thompson charged little, lived well and has no regrets.

I think what the Dr. Thompsons must recognize is that managed care does not represent a reckoning. They have cut orthopaedists' incomes in Connecticut by nearly 50 percent, but although they have discounted our fees to the point where they are putting us out of business, they still charge employers (and your patients) the full boat. They reassure businessmen and legislators alike that they have put runaway health costs under control and then pass the savings on to their stockholders and lobbyists.

I don't get it, Dr. Thompson. At what point am I supposed to cry, "Ouch?" In my office we have downsized 30 percent of our staff, and we work under the burden of that inconvenience. This winter we have been promised another salary reduction as Medicare continues to renege on its promise. In January, MD Health Plan will pay more for a carpal tunnel release than Medicare will for a total hip. Obviously, the public is no longer standing in awe of what we do - at least they're no longer willing to pay for it. Of course we'll slog on and provide "optimal care" to whomever the plans serve up to us - at three o'clock in the morning - but tell me the part where I have to feel bad about what I "charge." Eighty percent of our practice is managed care (to include Medicare, Medicaid and workers' comp). It doesn't make any difference what we charge. Tell me the part again about "no regret."

An old professor of mine once said, "You can always flog another ounce of guilt out of a doctor."

Ronald A. Ripps, MD
Danbury, Conn.

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