What's Your Doctor Worth?

How much money does your doctor earn?  If your doctor is a Surgeon practicing in rural central California, you're about to find out.

First, some background:  Perhaps your 51-year-old neighbor's screening mammogram this year showed a suspicious area.  She is called back by the Radiologist for more testing, including additional mammograms and an ultrasound.  She then receives a call from her Gynecologist explaining that the x-rays are "non-reassuring," and she'll be sent to a specialist in breast surgery.

That's where my office gets involved.  Five or ten faxed pages arrive on my assistant's desk.  She calls the Gynecologist's office to request additional material, including copies of the mammogram report, the patient's contact information and insurance data-if the patient is insured.

As it happens, like more than 60% of the women I care for, this patient is either uninsured or underinsured by Medi-Cal or BCEDP, the State of California's breast cancer detection program for low-income women.

The paperwork piles up.  Now my assistant must confirm eligibility in addition to scheduling the consultation, creating a chart and retrieving x-rays for me to evaluate.  Prior to the visit, I review the chart and create an electronic medical record.

Next, the visit.  Your neighbor arrives at my office.  I speak with her for about 15 minutes, learning her medical and surgical history, asking about symptoms and risk factors, and answering questions.

I examine her carefully, assessing not only for breast abnormalities, but also for swollen glands in eight regions of the body.  A heart and lung exam is done to identify problems that would make her a higher surgical risk, and the neurological, abdominal and musculoskeletal evaluations provide evidence for or against tumor spread.

After my patient is dressed, she asks me to bring her sister and husband in for the discussion of my recommendations.  This is often the most time-consuming part of the visit, requiring patience, repetition and reassurance for a frightened patient and her concerned family.

Although our first visit has ended, the work has not.  I fill out a form ordering testing to further characterize the abnormality seen on my patient's mammogram.  I'll pore over a list of codes required by Medi-Cal to identify the visit, choosing the most appropriate ones and hoping they don't merit automatic rejection of the bill (a frequent occurrence, prompting up to nine months of back-and-forth debate with Medi-Cal).  Because the necessary biopsy requires a Radiologist's assistance, I'll communicate with him as well as the Pathologist who examines the specimen provided.

The diagnosis is Breast Cancer, and it's my job to break the news.

Our second visit is very different.  Not only do we talk about her diagnosis, we review all of the options for treatment, alternatives and their possible outcomes.  There may be tears and anger, self-blame and fear, and the inevitable, impossible question: "Why?"

This visit is the most difficult one for my patient and her family.  I, too, find it the hardest part of being a Breast Cancer Surgeon.  Some wounds cannot be healed with sutures and sterile bandages.

Back to the question at hand: How much is your doctor paid?

What payment will be made for the initial consultation and exam?  What dollar amount is assigned to the time spent with my patient and her family, explaining and encouraging, counseling and comforting? 

Every doctor who practices independently must be not only a medical expert but also a good enough business owner to keep the doors open.  No amount of compassion, however critical to successful treatment, will pay the bills. 

Payment for a visit must cover the rent and utilities to keep the office open.  Office staff needs to be paid, their health and dental insurance premiums covered.  There are additional payments to be made for Worker's Compensation, malpractice and liability insurance.  Office supplies, medical supplies, biopsy equipment and disposable instruments are essential and expensive.  There are also laundry and cleaning expenses, postage and biohazardous waste service.  Your doctor must also pay the 24-hour answering service, the billing company, as well as the bookkeeper, accountant and attorneys.   And, like everyone else, your physician must pay Federal taxes, State and local taxes, payroll, income and unemployment/disability taxes.

Here are the actual Medi-Cal billing codes and payment schedule for central California breast cancer Surgeons in 2006:

For the initial consultation and exam of the lady with the abnormal mammogram:

CPT#99243 $59.50.

For the visit in which she is told she has Breast Cancer and is prepared for surgery:

CPT#99213-57 $24.00.
This is what your doctor is paid.  Now ask yourself what she is worth.

Dr. Halderman is a Board-Certified General Surgeon practicing in rural south Fresno County, California.
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