Money and Medicine


Many want to keep the two topics of money and medicine separate from each other.

However, that is not possible.

Healthcare is big business. A large percentage of our GDP is spent on healthcare. Over half of that expenditure is paid for by our federal government.

So, the two topics are intimately linked.

Often, doctors are criticized if there is even the hint of money matters entering into healthcare decision making.

But, they can't be separated. 

Things have changed significantly in healthcare in the last 30 years.

When I started my Orthopaedic Surgery, Total Joint Replacement practice in 1994, reimbursements were substantially higher for most all procedures. 

As a result, all of us in my group took care of self-pay patients regularly. And most of them ultimately were no-pay patients.

But, it was fine. Our reimbursements from the insured, paying patients more than made up the difference. 

We considered it part of our responsibility to the community.

Similarly, in my group at that time, we saw patients with Medicaid which paid pennies on the dollar.

Again, we considered it part of our duty to society.

As time went on, however, things changed dramatically.

Reimbursements from Medicare decreased annually. 

Insurance reimbursements became tied to Medicare, so they decreased annually, too.

No longer was there "enough to go around."

We had some tough decisions to make.

No longer could we afford to see no-pay patients.

So, we started collecting initial payment up front for clinic visits from self-pay patients. And since our practice was elective orthopaedic care, if they couldn't pay, we didn't see them.  It was a business decision forced on us.

Similarly, we found out that, at the nearby state funded medical facility, physicians were reimbursed at Medicare rates for seeing Medicaid patients.

Since we didn't receive those rates, and since our rates were actually pennies on the dollar, and since those patients had access to a facility that was glad to see them, we stopped accepting Medicaid as a primary payment. Another business decision forced on us.

In our group over the years, we kept our respective incomes from our orthopaedic practice relatively stable by increasing our efficiencies.

I even took two separate trips away from my practice to visit a mentor of mine in another state who had been somewhat of a pioneer in OR and office efficiency in total joint replacements.  

What I learned from him allowed me to see more patients and do more surgeries in the same amount of time.

By the time I retired in 2022, I did two-and-a-half to three times as many surgeries per year compared to my first ten years in practice.

That is what any business would do.

If a business is not able to increase prices, they look for ways to sell more items.

It doesn't mean they are selling people things they don't need.

They are just more focused on what will result in more traffic and more sales.

It's good business.

And even though the same thing occurs in healthcare, it is still good business.

I didn't talk people into total joint surgeries they didn't need.

I just saw more patients who had badly arthritic hips and knees, and once nonsurgical treatments were no longer helping, I was available to fix them when they were fed up with the joint pain and decreased function.

That's just good business.  Even if it is healthcare.

Let's face it, over those 30 years, there were also significant increases in expenses.

And those increases occurred without us being able to raise our prices or receive higher reimbursements.

The government mandated electronic health records. That was a large expenditure for our group.

There was no subsidy from the government. It came out of our pockets.

So, in our group, we all did what other doctors did. We coded office visits to maximize our income.

That doesn't mean we upcoded visits. It just means we paid very close attention to be sure we coded visits properly for a change.

Prior to the decreased reimbursements and the increased expenses, I always coded office visits at the lowest or second lowest visit level. In retrospect, it was clear that I was cheating myself, because many new patient visits could have legitimately been coded higher.  

But, when the whole business side of my practice changed with new regulations, I educated myself on office visit coding, and I made sure to cover all the bullet points needed to justify the coding for the visit level.

That doesn't mean I was greedy. That just means income had become a big issue, and I, like almost all doctors, just wanted to be adequately reimbursed for the work I was doing.

The system worked well before all the regulations changed. 

But the decision makers decided it needed changed. So, don't blame doctors for the consequences of those decisions! 

And with electronic data, there was the need for cybersecurity to protect that data.

That security required more software, more servers, more redundancy in the system for protection.

Ultimately, that required that we hire our own IT staff.

We also had to hire more staff to deal with insurance and Medicare regulations and compliance.

The more the payers denied care, the more staff we needed to work on appeals.

The more prior authorizations were required, the more staff we needed to work on them.

And as inflation increased, our staff needed raises to meet their expenses, despite the fact that we, the employers, were not receiving raises.  

So, like it or not, money and medicine are inseparable.

Because medicine is a business!

So when doctors have to make hard business decisions like all other businesses, they should not be overly criticized.

Doctors want to be adequately reimbursed for the time, energy, years of education and training, and the risks they take.

That is not too much to ask.

I know very few doctors who are truly greedy. Probably fewer than there are in most other industries.

When I was on call and had to go to the ER to see a patient, I never looked into or asked whether they had insurance or not.

I was the Orthopaedist on call.

They were my responsibility.

And I treated every one of them the same.

I didn't need to know their payment status.

And most of the doctors I knew while practicing felt exactly the same.

Money and Medicine are intimately linked.

No doctor should feel guilty about the business of healthcare.



​Ben Holt, M.D.