Healing Blues

Many physicians are sick of the financial side of medicine, such as low reimbursements from health insurers (plus mountains of paperwork) and high liability insurance premiums. We asked two doctors to share their decidedly different views on the nation's health care system. In particular, they debated whether a single-payer health insurance system would help both doctors and patients. Mark Eisenberg is a primary care practitioner at a Charlestown health center (part of Massachusetts General Hospital's ambulatory care division), and he teaches at Harvard Medical School. Henry Childs is a solo primary care practitioner in Maynard.

EISENBERG We're spending 31 percent of our health care dollar on administrative costs. If we could cut that down by having a single-payer health insurance system, then that money spent would drop substantially. Doctors wouldn't end up taking a pay cut; they would spend more time seeing patients.

CHILDS Within reason I agree. The costs of overhead, of meeting the huge demands of paperwork, are colossal. But as to whether anything can be done - I've been in practice for 30 years - I'm a little bit cynical about that actually happening.

EISENBERG I've been in practice for 18 years. We had two secretaries when we started; now there are seven. The MGH billing department is five times as big as it was 20 years ago.

CHILDS I've never been able to pay myself more than $50,000 a year before taxes. That's less than a third of the average MD's before-taxes salary.

EISENBERG I do a combination with teaching, but the MGH salary scale for a full-time doctor in practice for five to 10 years is $160,000.

CHILDS You're a little bit ahead of that, I imagine.

EISENBERG I don't see patients full time [55 hours a week], so it's hard to say.

CHILDS The 2002 median income for MDs in New England was $175,000 [25 percent more than in 1992]. But in that time the cost of maintaining a physician's practice in Massachusetts went up by 66 percent. The [Massachusetts Medical Society] also did a workforce survey of a couple of thousand practicing physicians, and the figure that sticks out in my mind is that 41 percent would not choose medicine again if they had to do it all over. It boggles my mind - almost half!

EISENBERG I love what I do, I find it really gratifying, I would be happy if my kids would do it, but I hear what you're saying. I do have a concern that applications to med school are dropping. Fewer are going into primary care. They're going into specialties, where they can make more and pay off their debts. When I went to medical school, it was around $4,000 a year.

CHILDS That's one of the big changes. When I graduated from BU med school in '71, the cost was something everyone could pretty well handle. Now, many students graduate well over $100,000 in debt. . . . And I love the work, too. I see five to seven patients a day - taking the time to ask questions, to establish a relationship with people. There's a perception that physicians are wealthy and arrogant, and some of us, we're not that wealthy. No, I honestly don't know that if we have a single-payer system that it will help, being at the whim of an agency. What Medicare does to physicians' reimbursements has hurt through cutbacks. Our job has actually been made harder.

EISENBERG But I don't think that's a function of the fact that Medicare is a single-payer system. It has to do with the federal government.

CHILDS When you have single payer, you have a monolithic entity that doesn't meet everyone's concerns.

EISENBERG But we spend 31 percent of our medical costs on administrative costs, whereas in Canada [which has a single-payer system] it's only 16.7 percent. That's a lot of money that could be spent on the 40 million people who are uninsured and instead get care late, in emergency rooms. We spend more money than any industrialized country in the world on health care, but our statistics are so bad.

CHILDS The mortality rate is certainly nothing to brag about.

EISENBERG If we take that money and insure all the uninsured, and doctors spend their time seeing patients rather than figuring formularies . . .

CHILDS But the problem is, who is going to run it? . . . And we haven't gotten to professional liabilities yet. Insurance premiums are very high, even for my low-risk practice. Many obstetricians have stopped [delivering babies] because their premiums are higher.

EISENBERG It is difficult for doctors. I just hate to shift the burden onto patients. I'd prefer a system of universal health care rather than a pieced-together system where doctors are forced to bill patients.