Picture of Ian Ross, MD

Ian Ross, MD

Dreary Cuts

The gray and humid desolation of the winter season hangs over me. I generally love this time of year, welcoming cool rains and fresh air after the hot, dusty oppression of the warmer months here in Southern California. But not this year. I try to think positive thoughts. But, having been tasked with writing a piece about the decline in pay that we are all facing, it is not easy.

We all know that a 3.37% Medicare payment cut went into effect on January 1, 2024.  Adjusted for inflation in practice costs, Medicare physician payment had already declined 26% from 2001 to 2023. The trend is undeniable, and seemingly unstoppable. What is a doc to do?

It is reaching a point where, like most households in America, a dual income spousal partnership has become a necessity. And when will it reach a point when the money needed for childcare for late hours and weekends is not going to be there? Do insurers and the government really think that we will be willing and able to prostrate ourselves to the service of our patients while having to pay for extra childcare that we can no longer afford? It is just not sustainable. To practice the way we do, independent wealth or significant spousal income is going to become a necessity; not for me but for generations to come.

There continue to be intelligent, well-educated people who take various forms of public service and academic employment, forgoing large paychecks for the privilege of working on and being part of projects bigger than themselves, the most obvious one being the military. This offers challenge, along with considerable discomfort and possible personal risk. Remuneration is poor, but subsidized higher education remains an enticement. It requires the services of young people and is therefore structured in a way that is attractive to that subset of the population. But service to medicine is not something that we sign up to do for a few years, after high school, or to handle the cost of higher education.

Circumventing Medicare is not easy. You can opt out, or choose to charge people a premium for added services, the concierge model. Most, but not all, neurosurgeons feel that they have a social contract. We are uniquely skilled at caring for certain acute emergencies that affect the nervous system. To forgo that aspect of practice for a boutique model of care for certain spinal or cranial disorders, while not wrong, limits the scope of practice to an extent that we do not all desire. Furthermore, widespread adoption of this model would cause other problems.

Debt from education is the most significant factor in determining pay for physicians. If we can get rid of debt, poor pay might seem less important. Or will it?

Physicians in the United States make more money than they do just about anywhere else. Docs in other countries are usually salaried and paid by the public sector which controls most healthcare spending. Public sector workers, including those is healthcare, throughout the world have also seen significant declines in remuneration, when compared to inflation, in recent decades. Governments are struggling to control costs, including those for care for aging populations for whom longevity and complex and expensive treatments have led to more and more money being spent per individual. US physicians are not the only ones who feel unhappy and undervalued.

A senior colleague once told me that before Medicare came into being, it was not unusual to charge 10% of a person’s net worth for a surgeon’s services for major surgery. This was not unreasonable when surgical options were limited and patients were not expected, or expecting, to live for very long, and large

numbers of patients had no insurance or means of paying for their care. But now, if you live to be over 80, there is a very good chance that you will have had several surgeries for joint replacements, cardiac issues and cancer before you succumb to old age, most of it on Uncle Sam’s dime. If you get certain types of cancer the cost can be incredible. The median cost for targeted therapy cancer drugs is over $200K per year per drug.

Governments are clutching at straws trying to save money. And “overpaid” physicians and surgeons are an easy target. But the surgeon is just the waiter in a very expensive restaurant. We get the tips, which are just a small part of the final bill.

The European model is very attractive from a cost perspective, but would require heavily subsidized university and medical school education for doctors (to avoid educational debt) and a government-controlled market for health care, with increased wait times and overall diminished service. The populations of these countries seem happy with what is made available to them. It is the best way to control costs. But are Americans willing to put up with such a system?

I started writing this piece on the shortest day of the year. A new year has now arrived. The days are perceptibly longer, but there are still many clouds in the sky. I do feel slightly more optimistic. Nothing, however, has changed. I have not said anything new, and I do not have any solution to offer.

The fact of the matter is that surgical specialists like us require expensive infrastructure and help. This infrastructure has always been provided by society, through religious groups, charities/philanthropies and government. We are dependent on these groups. They, not we, ultimately dictate the resources that are made available to help us provide services. The system, for the last half century, has become more dependent on government funding and we, therefore, are at its mercy.