[Paleopsych] Gary North: When You Won't Be Able to Find a Physician
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Fri Jan 21 15:17:28 UTC 2005
When You Won't Be Able to Find a Physician
Gary North's REALITY CHECK
Issue 397 November 19, 2004
That day is coming. The closer you are to age 65, the
faster it is coming.
You have to begin planning for this now. The care that you
will receive is going to resemble the Post Office.
When you are over 65, a physician who accepts any Medicare
patients is not allowed to accept payment from you if you are
under Medicare. It's a felony if he does. The only exception is
if you're covered by your employers' policy.
Because hospitals charge high prices to uninsured people,
but accept Medicare payments or insurance company payments for 20
cents on the dollar, if you aren't under Medicaid, you can get
ruined. Why does the government allow this dual pricing
practice? Simple: the bureaucrats know that this forces everyone
under Medicare/Medicaid at age 65.
Insuring yourself against a catastrophic illness with a
high-deductible ($5,000) coverage would be affordable, but it's
not possible. Private insurance companies do not cover people
older than age 65.
THE SQUEEZE ON PHYSICIANS
There was a time when "my son, the doctor" meant a lot. It
meant money, social prominence, and steady work. Today, it means
filling out Medicare forms, high liability insurance, massive
debts at graduation, and years of forfeited income early in life,
when the compound growth process should get started.
There are two physicians in my congregation. Both of them
have quit practicing. One is an official with Blue Cross/Blue
Shield. The other runs a business selling an amazing cream,
available only by prescription, that removes aging spots and
Back before World War I, the government first gave
physicians protection from competition. Then, beginning in the
1960s, the government has tightened the regulatory screws. "The
government giveth, and the government taketh away."
There is a joke about a physician who calls a plumber. The
plumber works for three hours and charges the man $150 for labor.
"Why, I don't make that much per hour, and I'm a physician." The
plumber replies, "Neither did I, when I was a physician."
Recently, I received a letter from a family physician. What
he says about his profession is not understood by the general
If he is correct, there is going to be a shortage of
physicians, especially highly motivated ones. (Note: "shortage"
always means "at some price.")
A PHYSICIAN'S WARNING
I am a family physician and teach medical students. One of
the things I try to help them deal with is the little-understood
(even by those in med. school) fact that by age 65, most family
physicians will have earned less than most factory workers who
are willing to work equivalent hours, yet the average
'proceduralist' physician will make within the first four or five
years of practice, more money than the family physician will
during his/her lifetime.
As a top-10%'er in my class, I had all the options, and had
the 'backup' of an undergraduate degree/license as a pharmacist;
that's now good for about $60/hr minimum. I had, unfortunately
for my family (income equates to potential time spent with
family), a 'calling' to be a family physician, in terms of
abilities, interest, and what I felt 'right' doing.
I will make the same amount of money by age 65 (if the
government doesn't screw up health care further by regulation)
slightly less than I would have if I got out of high-school and
signed on at $7.50/hr, working the same hours I now do, with
never any career 'advancement' besides a wage keeping pace with
My patients of course are clueless; they see the Mercedes
driven by a former classmate (I tutored) who is now a urologist,
and the big house of the family physician down the street who
signed on to work for the local hospital as a 'funnel' physician
(so they can get HMO contracts by having lots of primary care
providers); she works four days a week in the office, 9 to 4:30,
and takes telephone-only call 3 days a month (no hospital
practice required) and makes $115,000 a year. I'll make less
than that, and work a 60-hour week, with some months being
'negative' -- I've gone as long as 9 months without a paycheck,
if there are practice transitions going on (new partner,
So far, it just represents my willingness to take some
cash-flow risks, and my willingness to view medicine as a
'calling' rather than as a privileged license to take advantage
The problem is that, unlike most areas of business, medicine
is socialized, and there is no competition. The worst aspect of
this is that the patients pay several-fold more for health care
than they should have to, and get far less quality than they
ought to. (Ironically most of this is due to government-imposed
'quality-assurance' and 'cost-containment' solutions which are
actually insurance-lobbyist dreams-come-true but the public is
persuaded are to 'help control costs and assure quality.') The
reality is that a patient who presents with several inter-related
problems has three kinds of care they will encounter:
1. Revolving-door. They see a physician who schedules
20-25 patients per day, and 'works in' another 10; they
are in actual face-to-face contact with the physician
for less than five minutes, problems are minimized and
treated in a 'meets code specifications' type manner,
and that physician makes maybe $150,000 to $300,000 per
year for a 40-hour work week, usually with great
benefits since they usually work for an HMO or
2. Biopsy the Wallet. They see a physician who has
determined what that particular patient's insurance's
weaknesses are, and spends the slightly-less-rushed
encounter time to ask enough leading questions to
determine a 'need' for whatever well-reimbursed tests
or procedures the physician can 'capture.' That
physician may make a little more income, and work the
same basic hours.
3. Try to do the right thing. They see a physician who
maybe sees 2-3 patients per hour, and tries to do a
thorough history and examination and order whatever
tests are appropriate or do whatever procedures are
actually necessary. This physician will have a shabby
office, and you will spend an hour or more in their
waiting room, but will receive a caring and thorough
evaluation. That physician will make between $50,000
and $120,000 for a 60-hour work week, and have puny
'benefits' because they are likely self-employed. They
don't get the glitzy advertisements or marketing from
the local hospital or HMO because they 'buck' the
system and don't just skew their evaluation and
treatment to maximize the HMO profits so they can get
This is all due to the socialization of health care, and the
fact that when patients are seen, procedures (most of which are
very easy to do, and anyone with half a brain could do well, but
are 'restricted' due to government and medical-association
licensure issues) are way overpaid, and 'cognitive services'
(which is what the physician's 12-15 years of post-high-school
education are supposed to train us for) are typically
unreimbursed or paid minimally for. Example: If I treat a
diabetic hypertensive Medicare patient with lipid problems,
depression, and arthritis, and multiple medication interactions,
I may spend 40 minutes with them ($120 dollars cost to me in
overhead) and Medicare won't even pay me enough to break even
(I'd be better off sending the patient next door to see a
specialist who will do some $900 procedure on them and make them
a happy patient, and handing a $20 dollar bill to them to get
them out of my office, than to see them and spend those 40
minutes with them). On the other hand, if I dream up some reason
to do a procedure on them (ear wax removal? Skin lesion biopsy?
etc.), sick the nurse on them, and move on to the next patient
after 5 minutes with them, I may have a profit of $50 for 5-10
Yes, careers can be a 'calling,' but when my kids say things
like, 'Dad, why can't we ever go on vacation like the Smith's
[union factory worker], or have a swimming pool like the Jones'
[self-employed plumber], or just have supper together as a family
like the Johnson's [both school teachers],' I have no good
answers. The Smith's even have friends in the media, who caution
social planners to be sure to keep blue-collar workers from
having problems 'accessing' health care. The Jones family earns
public sympathy as small business owners that the private
practice family physician never gets. The Johnson's are in the
martyr class of Teachers, Policemen, and Firemen who are
reputationally under-paid, yet all attain a lifetime average of
more per hour than the family physician who refuses to 'play the
game' by practicing for the system instead of for the patient.
In a fair world (a capitalistic, free-enterprise one), I
could charge say $5 more per visit, and patients who valued the
extra time and better care would pay me $5 more than the doctor
down the street. Since the average profit per doctor visit is in
the $10-15 range, I'd get a substantial raise, encouraging and
rewarding me for 'doing the right thing' -- instead, they all pay
the same $10 co-pay, whether they go to the revolving-door doc,
the find-a-procedure-to-do doc, or myself. My income suffering
isn't the big deal, but my kids don't get family time, and they
will be lucky if we can send them to college, while the kids of
those who surf socialism's great 'safety net' will treasure the
many family vacations spent jet-skiing before they trod off to
their ivy-league colleges.
'Callings' are at least affordable in a capitalistic
environment, but as our society becomes more socialistic, they
are not going to be the way most people make life decisions.
WHO IS RESPONSIBLE FOR PAYMENT?
I rarely visit a doctor's office: maybe once a year. Two
more visits, and I'll be on Medicare. My goal is to pay cash,
despite my Medicare coverage. I figure I'm a more valuable
patient this way.
I use two physicians: a successful one and a conventional
one. The conventional one treats everyone, accepts Medicare,
accepts insurance company payments, and will have to work until
he's 70. The other is an "alternative medicine" physician. He
accepts no Medicare patients, accepts no third-party payments
from insurers, and requires payment after every visit. I can pay
him whatever he charges after I reach 65. He is not under the
He is booked solid for three months out. It's working for
In 1978, I spent two weeks lecturing to physicians in a
dozen cities. I was accompanied by physicians from Canada and
Australia. Two other teams like the one I was on also included
physicians from England. We warned physicians about the coming
of socialized medicine and government regulation. Attendance was
The Australian physician had adopted the practice of not
accepting third-party payments. That way, he got paid on time.
He also attracted patients who were after top-flight service.
That, he provided. He recommended that every American physician
adopt such a procedure. Few did.
The idea is now spreading. The Association of American
Physicians and Surgeons have adopted The Physicians' Declaration
of Independence (July 4, 2004). Its opening paragraph is a shot
across the bow of socialized medicine.
When in the Course of human events, it becomes
necessary for one Profession to dissolve the Financial
Arrangements which have connected them with Medicare,
Medicaid, assorted Health Maintenance Organizations,
and diverse Third Party Payers and to assume among the
other Professions of the Earth, the separate and equal
station to which the Laws of Nature and of Nature's God
entitle them, a decent respect to the opinions of
Mankind requires that they should declare the causes
which impel them to the separation.
The rest of it is equally good. Paragraph 2 is basic.
We hold these truths to be self-evident: that the
Physician's primary responsibility is toward the
Patient; that to assure the sanctity of this
relationship, payment for service should be decided
between Physician and Patient, and that, as in all
transactions in a free society, this payment be
mutually agreeable. Only such a Financial Arrangement
will guarantee the highest level of Commitment and
Service of the Physician to the Patient, restrain
Outside Influence on Decision-Making, and assure that
all information be kept strictly confidential. When a
Third Party dictates payment for the Physician's
service, it exercises effective control over the
Decision-Making of the Physician, which may not always
be in the best interest of the Patient. The Third Party
then intrudes heavily into the sacred Patient-Physician
relationship and demands to inspect the Medical Record
in a self-serving attempt to satisfy itself that its
money is being spent in accordance with its own
pre-ordained accounting principles.
The declaration ends with this forthright assertion:
We, therefore, the undersigned Physicians of the United
States of America, appealing to the Supreme Judge of
the world for the rectitude of our intentions, do, in
the Name of our Patients solemnly publish and declare,
that we will withdraw our participation in all
above-described Third Party Payment Systems. Henceforth
and Forever, we shall agree to provide our services
directly to our Patients, and be compensated directly
by them, in accordance with the ancient customs of our
Profession. As has always been true of our Profession,
our charges will be adjusted to reflect the Patients'
ability to render payment. Nothing prevents any patient
from purchasing and using Insurance. The Patients'
medical interactions with us will remain completely
confidential. We pledge the highest level of Service
and Dedication to their Well-Being.
And for the support of this Declaration, with a firm
reliance on the protection of divine Providence, we
mutually pledge to each other our Lives, our Fortunes
and our sacred Honor.
To put all this into a form that most of us recognize, he
who pays the piper calls the tune.
I want to call the tune. I can call it by paying. If my
physician has structured his payments system to treat people like
I am, he will be responsive to my demands.
But what of my local physician who is booked up for three
months? He isn't charging enough. He is rationing access by
making us wait for months. He should offer an "emergency
appointment" option for an extra $100 per visit. That would be
allocation by price.
As more physicians get the message, he will have
IF YOU GET SICK
By relying on third party payments, Americans have passed
the buck to third parties. They have chosen low-deductible
policies, paid for by employers. This has led to the usual
scenario: the insured try to maximize their "free" care, and the
companies try to reduce payment. Costs soar. Employers are
trying to get out of the insurance-provision business. The
health insurance industry looks more and more like Congress.
The physicians are caught in the middle. They are expected
by everyone to charge less per visit.
So, my advice is this: don't get sick. Take responsibility
for your health. Do the things you know you should, and avoid
the things you know are bad for you.
The fact is, the largest single medical expense of your life
will be your last six months of life. About two-thirds of
everything you will spend on hospital and physicians' care will
be spent in those final six months. (This, according to the Blue
Cross/Blue Shield man in our congregation.) So, Medicare will
bust the fiscal system as more old people start dying. The
expenses have only just begun.
This means that having an HSA policy is a good idea. These
are tax-deductible medical policies. You deposit money on a tax-
deductible basis. If you get sick, you can spend this money tax-
free. The system will be abused, then reformed, then abused, and
so on. But for now, HSA's represent a major savings.
Establish a good relationship with a physician today, so
that he will continue to see you. Pay cash. Don't make his
secretary fill out forms unless the expense is really high.
A social relationship is important. Give him a book that he
might like when you visit his office. You just happened to pick
it up. Talk about things he is interested in. Send him a nice
Christmas present. Yes, even if he's Jewish. If you know he's
interested in sports or other events, buy two tickets and just
happen to have an out-of-town event pop up, and does he want
them? Do this before you hit age 65. Establish a pattern early.
Living in a small town is better if you're over age 65. In
a popular retirement area, you will sit in a large office that
looks like Grand Central Station. You will get 10 minutes of
time with the doctor. It's all Medicare, all the time. If
you're in a small town, maybe there won't be a large office area.
You'll get in.
We are about to hit the brick wall in health care delivery.
If you can find a physician who doesn't accept Medicare, go
there. Pay up front. Be sure he wants you as a patient.
The younger he/she is, the better. Get in on the ground
floor, when there is no patient base. A hungry physician is
happy to see you. Over time, it will be harder to get on the
Basically, the government is substituting rationing for
price competition in health care delivery. Under such
conditions, you must seek out legal ways to get to the front of
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