Doctors Work the System to Increase Income – at the Patient’s Expense

Found an interesting op-ed from the Dallas News online yesterday, written by Dr. Steve Cole entitled, Biggest factor in rising health costs are the doctors themselves.” Unfortunately, the title doesn’t even begin to touch the content, so many folks will miss this enlightening piece — a piece that should be read by everyone who has an interest in the costs of healthcare.

The article explains many of the reasons healthcare costs go up based on a doctor’s wants and needs and not necessarily on the best interests of the patient. There are a few statements that should make all of us pause — because they speak to the real problems of increased costs. I give Dr. Cole plenty of credit for citing these points — and no doubt he’s taking plenty of flak from his physician-colleagues for raising them.

Doctors don’t order tests, or refer their patients to other specialists because they are necessarily best for the patient. They do so because there is a financial incentive to do so. Such as:

  1. A doctor orders a medication for his patient because he gets a higher reimbursement for that patient’s visit. The patient is considered to have a “more complex” ailment.
  2. The same is true for ordering a diagnostic test. Diagnostic test = higher reimbursement for that particular visit.
  3. A doctor will refer his patient to an additional consultant / specialist for the same reason. Only this time there is an additional financial incentive. By making the referral, he becomes part of an inner circle of sorts — and eventually may be rewarded by those specialists for sending patients their way. Sort of a medical referral commission, in effect.
  4. Dr. Cole suggests that much of the test ordering is about staving off litigation, too. Honestly, however, I’m not so sure it’s a fear of litigation. Instead I think it’s CYA (cover your a**) — because, if a medical error or misdiagnosis results, then all the tests in the world won’t avoid litigation. Instead, I think it’s just about having all that data and evidence amassed just in case there IS litigation. (As in, “But your honor. I tried to do it right! Look! I ordered all these tests!”)

What’s the bottom line for us savvy patients? When we think as patients — people with symptoms who need a diagnosis — we want to be sure we are getting the RIGHT tests and visiting the RIGHT specialists. We can determine that, at least fairly closely, by asking our doctor some questions. Why are you ordering this test? What do you expect it will tell us? What if it doesn’t tell us that? Is there another test that will be required? — or — Why do you want me to visit that specialist? Is there any other specialty that might might address the symptoms I’m having? And why are you sending me to this particular doctor? (if you determine it’s because they are friends, or are in the same practice, or even down the hall, then you’ll want to assess whether that doctor truly is the best one for you to see.)

When we think as consumers, then we want to be sure we aren’t getting any more tests than necessary, and that the cost of the test is fair. The literature is rife with doctors ordering tests only because they own the testing equipment and can bill insurance for it! That doesn’t necessarily help the patient, but it most definitely helps the doctor’s bottom line.

Truth is — doctors deserve to make a living and they deserve to max it for themselves, too. I don’t think it’s the doctors who are at fault for taking advantage of this system that is set up, like so many others, to fail patients. It’s more a question of looking at how reimbursements are made, and whether they support a patient-centered model of care.

And that’s another blog post for another day.

……………………….. See Follow Up Post to this Discussion ………………….

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Posted in: Doctor Communication, Health /Medical Consumerism, Health Insurance, Healthcare Quality, Media, Medical Errors / Mistakes / Misdiagnosis, Patient Empowerment, Patient Tools

Leave a Comment (15) ↓


  1. Trisha Torrey December 20, 2007

    This post has dearly hit a nerve — see follow up post here:

  2. Kathi December 31, 2007

    I recently experienced what I believe to be cover your backside medicine. Our local hospital, and the 911 paramedics as well seem to treat anything related to any kind of chest discomfort as though it is heart related–even if there are good reasons to think it was respiratory or other problems. I am a 61 yr old female with slight asthma, and past pneumonia 4x, but no history of heart problems and none really in the family. Although my Mom had a slight stroke in her 70s and my 93 yr old Dad had a stroke we didn’t even know about.

    A couple of mo ago I was in the garden and made the mistake of squirting some boric acid powder, I guess from too far up in the air, at some ants. I late noticed this powder suspended in the air and then started to not feel so good with a funny feeling in my chest/bronchial region. I went inside and it was starting to feel worse and I was scared and afraid that it might close up completely and made the mistake of calling 911. In retrospect I should have called the poison control center.

    The paramedics came out and did their checks and before they came out, I had vomited just a bit ( I suspect that I may have also swallowed some). I later did call the poison control center and they said it was a mild acid and that taking a hot, steamy shower for 20-30 min would have been appropriate. But at the time, I was afraid.

    The paramedics asked my level of pain. I told them it wasn’t pain, but they pushed anyway to give a rating on a scale of 1-10. I had told them that I had inhaled boric acid powder. After I gave them a number since I was feeling discomfort, they pushed me to accept nitrogylcerin, telling me that if I took it, they would have to transport me.

    They gave me a puff. Somewhere along there, they hooked me up to an EKG and ran it. Then after getting ready, transported me by ambulance, starting an IV on the way. It was about a 6 mile trip. They gave me a choice of 2 local hospitals and I didn’t have a preference.

    When I got in there to the ER, I was waiting for them to take a med history and was surprised at how cursory it was, and it was awhile before they got to that. I told them again that I had inhaled boric acid powder, and I had gotten it and the paramedics had brought it along. They seemed somewhat befuddled by that.

    To make a long story short, they had me scared a bit thinking maybe it was my heart, although I really thought it was my respiratory passages. I told them I had asthma. Other than listening to my chest–without even having me cough–and then taking a 1 view chest x-ray, they apparently dismissed that. They continued on and listed my complaint as chest pain, which it wasn’t really. I also recently got the medical records and was dismayed to notice that rather than listing that I had INHALED the boric acid powder, they just said I had been exposed to it–no wonder they seemed befuddled.

    They kept me in the ER for some time on monitoring and then said they wanted to keep me over night to make sure. I was not feeling well (I had real chills in the ER among other things and I had not eaten that day and they wouldn’t give me anything to eat, until probably 4 or 5.) They had me almost believing it was my heart, and being alone I wasn’t thinking totally straight. So they ended up admitting me to the cardiac ward.

    By the following day, I was feeling better and thinking straighter and refused a treadmill stress test as they had indicated that they hadn’t found anything and I do not have insurance.

    So, upshot of all of this, they immediately ignored that I said I had inhaled the boric acid powder, and there was no indication that they consulted with the poison control center and they didn’t seem to know what to make of that and just treated me as a cardiac patient.

    In addition, living near the Orange County, CA fires, I had inhaled some smoke from the fires, just in the course of needed errands and my respiratory passages were somewhat irritated even before this and I think I told them that.

    So, they did not find any cardiac problems and they didn’t bother doing anything for what was apparently respiratory irritation from a mild acid. And now I have a bill for over $8200 for the ambulance, hospital, etc.

    I feel that they just jump into cardiac mode if there is anything at all to do with the chest, whether or not they really think that is the problem. About 10 days later, the paramedics were called for the 95 yr old across the street and I was out front and talked to one who remembered me. he asked how I was and I said fine (actually I still have some lower respiratory irritation) and I told him it wasn’t my heart. he said he didn’t think it was. I sure wish that he would have said that at the time!

    And now I’m stuck with the bills that they keep dunning me to pay and I don’t have the money and especially to pay for treatment for what I didn’t have.

    In addition, although Tenant hospitals had a lawsuit which among other things was settled with some kind of an agreement to not charge uninsured more than the rates insurance co’s pay or maybe medicare. The charges seemed excessive. Plus they didn’t even ask what tests I had had done recently and they repeated many that i had had done about a mo before in the way of complete blood screening work. That was over $400 and I’m not talking about the enzymes for heart attack tests.

    A patient care person said something about seeing if she could get me Medicare rate, but that didn’t happen. They sent forms that were very invasive, asking for income tax info.

    While this is not as bad as the horrible cancer misdiagnosis, they did scare me and did not correctly record what had brought me in there. It seems a case of cover their back side in case it could be a heart attack whether they think it was or not–and they didn’t even really discuss the likelihood of it being a heart attack.

    I do not know what to do about what I feel are unjustified bils. I did pay them $1000 on discharge, but the various ones, hospital, ambulance and ER dr as well as a lab keep sending the bills. The hospital seems to have really overdone it. Several days after I was released, I got a phone call from billing to discuss it. Then about 2 days later I received a bill in the mail, along with another day some type of fin aid forms–we had already filled out ones while I was in there and I don’t seem to meet Medicaid qualifications I guess since I don’t have kids. And the county program since I do have a small retirement account. Then about 2 days later I received another bill, just confirming info they said. Then maybe 10 days or so later I got an updated bill that added a few charges. This seems like overkill, and not very efficient use of resources–undoubtedly running up their expenses–and it has been really depressing getting all these huge bills for just over night. The only one that seemed reasonable and which I gratefully paid immediately was the cardiologist who read the EKGs the following day and came by to see me as well as telling me that it was ok that I not do the stress test. I was pleasantly surprised that he only charged $30.

    I don’t know what to do about these bills for treating me for the wrong thing.

    About 5 years ago my Dad who at least has Medicare HMO ins had a somewhat similar experience, although his may have seemed more likely to be a heart attack. Same hospital adn he was about 87 or so at the time. This hospital is located basically across the street from a very large retirement community so they get a lot of elderly patients.

    he had a tight feeling across his chest so I took him into the ER at the same hospital. I expected that they would check and release him, but no they admitted him and decided that his discomfort was angina. They added additional blood pressure medicine and kept him for several days. I tried to ask if they really thought that was it, but it was hard to talk to the cardiologist as I was working and he refused to give me a call–he would only talk to me if I was bedside when he made his appearance and of course you never know when that might be.

    Dad was admitted 3x in a fairly short period of time, each time coming in via the ER and being admitted for angina. I increasingly tried to question this diagnosis but was brushed off. Finally, the 3rd time I was pushing for something more definitive and so brought up an angiogram which had been mentioned. The cardiologist said he’d never done one on anyone that old and didn’t think anyone in his practice had either (remember they have lots of elderly patients at that hospital). I requested a 2nd opinion and that dr sort of laughed and said he was probably one of the younger patients. Turned out his heart was ok. I’m guessing it was digestive system related for him. He has since been diagnosed with a hiatal hernia.

    While I think his case was more suggestive of heart problems, I think they should have been asking more questions much sooner about possible alternative diagnoses. But in both his case and mine, they seemed stuck on the heart attack scenario.

    I don’t think the drs were trying to make more money–although I really don’t know–but it really seemed like cya medicine. In his case, Medicare and his Medicare Advantage plan paid more than they should have had to probably and in my case, I’m being billed for being treated for what I didn’t have and not treated for what I did have.

  3. Trisha Torrey December 31, 2007


    thanks for posting.

    In fact, one of these folks may correct me, but I believe that any heart-related diagnoses in an ER are more expensive, and are reimbursed, at higher rates than a “simple” poisoning. One is probably considered more life-and-death than the other.

    Can any of you ER or health insurance folks weigh in on this question?

    I do hope you’re feeling stronger. My advice is that you make an appointment with the bookkeeping/billing people at the hospital and see if you can’t negotiate a lower bill with them.


  4. Kathi January 1, 2008

    Thanks for the response. Any other suggestions would be appreciated as I’m not sure what to do. I’m angry that they ignored what I told them and respiratory indications and just jumped on chest pain–even though I told them it wasn’t pain, etc.

    Well, I’m sure that the heart workup that I was given was more expensive than what would have been required for what I apparently had, which was apparently irritation to the lower respiratory passages. Probably some kind of breathing treatment would have helped and taken care of the problem, but I didn’t get any of that. They didn’t even ask me to cough when they listened to my chest.

    The chief complaint listed was Chest Pain and I was described as Diaphoretic with N/V after using Boric acid in her yard. NSR in the field O2 states 97% on 15L. (I don’t know what the initials mean.

    There was also a Reason for consultation by a physician which includes a note which I totally don’t understand that says “…patient stated that she had to use a port-a-catheter for cleaning…..” I never said that and am not even sure what a port-a-catheter is.

    The chest X-ray results said single AP portable view shows no material infilrates in the lungs. No cardiomediastinal abnormalitieis are visualized the bony structures are intact. No abnormalities demonstrated.

    I had also told them and they noted that I have asthma.

    So apparently what I had wasn’t serious but its scary when it feels like your chest is closing up and you might not be able to breathe if it keeps getting worse. Its been so long since I had felt that way with a bad asthma attack (and I’d never had to be hospitalized with that, but had spent some nights gasping for breath years ago. And then I had learned to calm my self, but hadn’t had anything like that in years and had forgotten some of that.

    In retrospect, I shouldn’t have called 911 since they seemed programmed to treat things as though they are heart related, even if they don’t really think they are.

    In the future I will be afraid to call 911 after this.

    I’m angry though that they didn’t even record properly what I had told them about INHALING not just being exposed to the boric acid powder. They didn’t seem to know what to make of that and I saw no indication that they contacted poison control.

    They also had other errors that looked like they made them look better or protected. Example they wrote I had refused a rectal exam. No I didn’t–it wasn’t brought up. They also said I refused the stress test which is correct, but they also said that they warned me of potential dire consequences which is not true. The cardiologist bascially agreed that I didn’t need it.

    My impression is that they are so focused on possibly missing a heart attack and being sued that they over emphasize that to the exclusion of considering other more likely scenarios. Like in my case, poison control says boric acid is a mild acid. I’m guessing that irritated my lower respiratory passages, which could easily cause the discomfort I was experiencing. They didn’t seem to consider that at all though.

    And a lot of it was my vulnerable position of being home alone and not having someone that I felt comfortable calling to help me. I had to make other calls and they did let me use my cell phone. My 93 yr old Dad was in day care and I had to call our car pool partner to pick him and his Mom up. And then I had to let people at church know that I wouldn’t be there to help with our Harvoween festival that night. And I called neighbors and my Dad because I was concerned about him being home alone. He can be home alone during the day ok, but I was quite concerned about him spending the night alone. So I was still in my caregiver role for him but did not have any help for me, in helping with decisions, although friends surprised me and did visit that evening. And then she offered to pick me up the next day and so I called her and she did.

    My brother lives in another state and my best friend was a new grandmother and busy helping her daughter. If I had someone else at home, I might have felt ok to wait and see, but I was afraid my respiratory passages would close up and I might not be able to call for help. I guess I should have pushed myself to call someone, but when not feeling well, and feeling a bit scared, its hard to think straight.

    But in addtion, again, I’m angry that they jumped on what they described as chest pain–even though I said it wasn’t pain. It was like they had blinders on or something as soon as they heard anything about chest discomfort. And they didn’t really ask about other medical history–just heart related and of course allergies to meds. And I’m not always very good at articulating what I’m sensing which was that it was respiratory. That’s what I thought it was all along, but I guess I didn’t insist clearly that I thought it was respiratory–although I would think that telling them I had inhaled boric acid should have led them to consider that and maybe check with a respiratory type specialist rather than just cardiac.

    Physically, I’m feeling mostly ok, although there is still some irritation. But being dunned for money to pay for treatment that I didn’t need and I’m not really sure how to deal with this is depressing. And I mean literally as i have a history of some depression and this has contributed.

    And they didn’t ask about any history of tests or anything that I had had done recently and I had been checked for cholesterol, blood sugar and a pretty complete blood workup at the community clinic about a mo or 2 before–at very discounted rates.

    And they didn’t discuss stuff with me, other than that the paramedics did ask for consent before the nitrogylcerin, and the ER also before admitting me, but they were pushing that way and I didn’t have the energy or will or whatever at that point to be assertive and ask more questions. They really just were pushing that way, not really giving clear alternatives. And they had me scared for awhile, making me even wonder whether it might not be my heart.

    But I’m wondering why I should have to pay for treatment that I didn’t need for a condition that I didn’t have and when they couldn’t even get key info like that I had inhaled the boric acid powder recorded properly. I already paid $1000 on discharge.

    Of course in addition to the hospital there is over $1100 for the ambulance and around $500 or so for ER dr and then something for a lab. I haven’t looked closely at all the bills, but it seemed like I was getting triple billed for blood work. The hospital billed me for sticking me, and for the blood tests, and then there was a separate bill from a lab.

    And in addition, it was I think and hr or 2 after they decided to admit me before they had a bed–so I was charged additional ER time by the hr because they didn’t have a bed ready or something to transport me or whatever.