Are doctors corrupt?

HealthCare Theory and Planning 101:  The major driver of excessive cost and poor quality medical care in the United States is the misalignment of financial incentives.  In a fee-for-service environment doctors do more exams, order redundant tests, and perform unneeded treatments, because the more they do, the more they are paid.  You eat what you kill, even if it is the patient.

At the heart of healthcare reform is the alignment of incentives.   This means either financially punishing docs for excessive, out of date, poor quality care, or increasing their income when they do the “right” thing. The carrot and stick approach to re-educating irresponsible physicians. The future rides on the idea that if you fix the dollars, you will fix the docsThey are wrong.

Corrupt: having a willingness to act dishonestly in return for money.   If it were true that physicians compromise human health to enhance their own incomes, then such a horrendous callous neglect, deliberately or not, of their oath and profession would be the very definition of corruption.  Hippocratic would be purely hypocritical.

The problem with this idea, on which healthcare pundits hang tomorrow’s patient care, is that it ignores the reality of how medicine is actually practiced by the average doctor.

In my entire career I have never made a single medical decision based on how much money it would mean for me.  Please note that I said 100% never.  In addition, I have never, not once, heard a physician justify a medical recommendation by the need to line their own pockets. It is not that there is a secret rule never to mention such an abomination and betrayal; it is simply not how doctors make decisions.

I am not so naive to ignore or discount that there are a few greedy morally starved bad actors that pathetically call themselves physicians, but they are uncommon and must be ostracized and exiled, not addressed with pathetic incentives.  You cannot fix evil with good works.  I also understand that there are sections of the healthcare industry that are heavily profit motivated. However, the vast majority of docs, while they desire and deserve a solid income, do not consider their own welfare when deciding how to treat patients.



No medical school lecture has ever discussed profit as the primary or secondary goal of individual medical planning.

– No authoritative medical research article ever recommends an intervention based on making more money.

-No medical conference, tumor board, M&M or data discussion ever supported a higher cost, higher margin, poorer outcome therapy, simply because it was a chance to make big bucks

-Of all the professional disagreements I have ever had or heard, none were about trying to choose the most profitable therapy over the benefit of the patient.

-No multiple choice examination answer was ever “A and C”, where A is a treatment and C is the largest amount to bill.

-Medical education does not even contain a class on economics, financial planning, investments or double-entry bookkeeping.


Doctors are motivated constantly by the fear they will make mistakes and by guilt from the mistakes they have already made.  They do their best for their friends, family and neighbors, patients all.  They focus on healing with the intention of helping their fellowman.  Notoriously ignorant about budgets and finance, trained to ignore cost, they may do too much and spend too much, but it is because the bottom line, anyone’s bottom line, is simply not on their radar.

While a small percentage of minor individual health decisions may be subtlety influenced by reimbursement, the vast majority are not. Therefore, if I am correct, if riches are not a primary motivation, then “aligning incentives,” paying doctors more to do a better job, will fail to control costs or insure quality.  A “reimburse for quality strategy” will have marginal success.  Doctors will continue to make the big decisions, which they believe produce the best result, regardless of what it does to their income.

Doctors are not corrupt.  Paying them more to modify that which they have already committed their lives will fail. Therefore, how should we “fix” doctors?

The answer is data.  Doctors respond to objective high quality information about benefits, side effects and net results.  Physicians wish to give perfect care.   Therefore, if they are told that a test is redundant or useless, a treatment too toxic or that the most effective remedy is the safest and simplest, docs will change and implement.  If you give physicians actionable feedback about the results of their own practice, they will listen, learn and act.  Doctors are about doing the right thing.  To change their practice you need only to show them what that is.

Some will say that I am ignorant to the reality of human nature.  I say profit based decision making is foreign to a profession whose primary drive is altruism, whose discipline is science, whose love is the art of caring and who are reminded everyday of the frailty of life and their fellowman.  Corrupt that motivation and reform efforts will fail.


  • Mary
    True for all but one of the docs I have encountered in my journey. He insisted I pay him cash because he didn't "accept"my insurance. Then he thought I wouldn't notice amidst the avalanche of EOB's that he was paid 100% by my insurance. Came unglued when I demanded my cash payments back and dropped me as a patient. Yes, I got it back after getting a lawyer involved and good riddance!!
  • gopja
    I agree with you. That being said, I ran across one of the 'outliers' after moving to the big city. Imagine my disbelief when this clown ordered cisplat as opposed to carbo because 'you can bill for the infusion hours, and we will hydrate daily for nausea' (and she was, horribly nauseous). I lasted about 3 weeks with that fool. Keep the faith, Doc.
  • Liz
    I think there are more doctors out there than you think who skim the system, order tests probably not needed, etc. rather than outright "bad" doctors. I have run into what Mary mentioned twice so far in just the last two years with 2 different doctors. One said, "Oh I just credit it against future care. Really? Then why isn't it showing as a credit on my account?". After an extensive argument I got my money back. The second "apologized" and returned the money quickly except I'd bet they were hoping I'd think if they were nice about it then I'd think it was a mistake and not report them (no, based on what went on I am positive this was deliberate and they hoped I'd not notice). I spent over 180 hours battling with a university medical center billing office over this kind of stuff - in this case I don't think it was the doctors I think it was billing that was dishonest (either due to incompetence or someone's directive). Some studies have found up to 1/3 of hospital bills have extra charges in there for things patients never received. Of course $37 aspirins and $14 ordinary bandaids (both off of medical bills of mine) are another way to scam the system. Ordering unnecessary tests for defensive medicine or outright fraud is not uncommon. My daughter saw a counselor where the entire practice was engaged in insurance fraud (seeing people for 30 min and billing for an hour). I think you are right that the actual "dirty" MD, who injuries the patient due to financial reasons or has absolutely no regard for the patient's wellbeing is probably not all that common, however ripping the system off in ways that less impact direct care choices I think is far more common. Of course when you have high profile cases (be it with this or in bankruptcy with student loans where they changed the rules due to perceived abuses of the system due to a couple of high profile cases yet overall less than 1/2 of 1 percent actually were declaring bankruptcy and getting rid of loans that way - so unlikely there were the "wide spread" abuses the new laws were "addressing" by removing bankruptcy as a viable option… and I'd guess this same reasoning figures into some of the reasons. One of the cognitive biases is that we take isolated events and presume they are more widespread/common. The we have the other reason - profit motive on the part of health insurance companies. While the law was changed to require a certain percentage of premiums be spent on direct costs of health care with the rest begin returned to the person who paid the premium helps limit that I am not so sure that applies to medicare or medicaid and both of those systems are huge. I'd bet that goes into some of the new rules. If economists are involved, one widely accepted theory of what drives human behavior (by them anyway), is that people purposely act in their own self interests and need carrots and sticks to "align their interests with the company owner" because left to their own devices the'd do what was in their own bests interests regardless of the effect on the company. There is then the assumption that "the market", in this case reputation effect and so if you engage in only self interested behavior you won't get another job because you'd have a bad reputation, is the other thing that reigns in self centered behavior. (This is called Agency Theory). While other disciplines recognize that there are other drivers of human behavior, there is a strong dose of economics in business degrees. So if insurance companies have decided doctors will want the insurance company "star" ratings because we will only pick a "high star" doctor, then the business school trained bone heads who dream up schemes like this might have a point. However I'd suspect that they want to drop from their network any doctors who are "expensive" for the insurance company as many companies don't make maximum profit thus not return any profits. If these return laws don't apply to medicaid, chips and medicare then this scheme will increase their profits. Not thinking about unintended consequences is a common failing of many managers, and if they are looking for fraud, even when it isn't there in great numbers, it is more likely they will apply a sledge hammer to the nail when a shoe heel will work. If they do not understand the underlying problem and what drives it then any solution they dream up will be addressing the wrong cause and be ineffective. And of course then you can have a solution in search of a problem and so twist the data to fit someone's brain child. Then confusing how you run a for profit company where you are trying to cost contain building a widget, where costs can be standardized and predicted to human health care where neither hold adds to the problem. Not all solutions transfer across different kinds of problems that on the surface appear similar. And of course they then create more problems than they fix. If politics are involved then all bets are off for any solution having anything that makes sense since compromise, trades and special interest tack ons generally doesn't result in bills that effectively address the problem.
  • meyati
    I doubt anybody will get this far after reading Liz's comments. I just left a PCP that seemed to have a financial investment in the clinic. He was an HMO doctor in a small HMO site. I was nagged to use that lab. It belongs to the lab company that I've been going to for years. I live 4 blocks from a oncology lab that's more comfortable and has longer hours. I was nagged about changing my GYN. It was low key finance-no double billing, etc. But somehow I felt that his investment was more than emotional. Most problems that I had were caused by bookkeepers double billing.
    • Liz
      Conflict of interest can also be a problem. When I was a grad student, student health services was the gatekeeper for the self insured student health insurance. I had my breast cancer ignored for 4 years as they wouldn't OK a mammogram. Turns out the docs got to split most of the left over money in the insurance fund if there was money left over. Sigh.
    • Liz
      Oh I think they will get this far as they probably saw my long comments and skipped them LOL
  • D Someya Reed
    In a perfect world what you say might be true. In the real world not so much. I think you, as usual, downplay the percentage of "bad eggs" to put a positive spin on the overall topic. This is the typical "I've seen more good than bad" logic applied to most all industries that come under fire either constantly or intermittently. Unfortunately, doctors are not always the ones in control of their individual decisions when "standard of care," administrators and insurers are involved. Just as they cannot order some things they might want to there are others they should but cannot because..."it's just not standard of care." And standard of care is driven by money even if it's only based upon a cost/benefit analysis to the patient. Most often doctors don't make this call but have to live by its injunction. When I was in college there was a group of five of us pursuing medical degrees. We were each asked why we chose this field. Only one of us answered something other than "the money." Not a good ratio for altruism even back then. To say, or imply, that doctors know nothing about money or finance...well, you know what I'll say to that. I agree with you, however, that money as incentive for positive change is never a good solution. Are doctors corrupt as a rule...probably not in the defined sense of the word. Can they be corrupted or ruled by the corrupt...oh yes, they most certainly can. Would they openly discuss it or put it in print say in a prestigious medical journal as you suggest in your points to "consider"...preposterous to even consider.
  • I love this topic because it affects all healthcare professionals that bill for their time. I see the comments left by both patients and doctors. In truth, all healthcare providers give good advice to every patient and will continue to do so, even when this advice may cost them time and money (interchangeable). We are really talking about two transactions, first the care provided by the healthcare provided and then secondly the fee paid to that provider for the service. These are not the same and unfortunately patients have come to believe they are connected. Do doctors and other health care providers "deserve" high pay? If the pay was not commensurate with the level of study involved to provide the care required, then the quality of the first transaction, providing care, will suffer. Ultimately, it is the patient who pays the price of reduced healthcare provider pay. Students who decide to pursue healthcare careers have choices, they can pick an equally high paying career in finance, software engineering, business etc., however they bring their much needed intellect to medicine. We need to remember that we need talented students to become our healthcare providers and we will not be able to attract these students with meager pay.
  • the society has no right to expect doctors alone being different from it in general ,in these times most of the professions have examples of the corrupt and in some more some less after all doctors too are humans like any others and are prone to greed selfishness and other crass qualities of every human and one cannot expect a doctor alone to be beyond suspicion ,saying that one also has to say that the sincerity of the whole medical profession cannot be looked at with the tinted glass of the few corrupt for as mentioned in this article a great majority are sincere and are willing to do their best for their patients at times sacrificing their time and pleasures many are noble indeed and i have always found society a bit ungrateful for their efforts
  • Penny
    As has been sort of pointed out, it's not always up to the doctor; he/she often has a hospital bureaucrat or two looking over his/her shoulder. Teensy example: small town doc has admitting privileges at local hospital; same small town doc has patient who works as a rad tech for said hospital. Rad tech has the flu, is running 104 F. temp. when she sees doc. Rad tech is sent back to work in the hospital instead of home to bed, not because doc thinks it's a great idea to send a patient to work in such a condition, let alone expose other patients to her illness. Hospital administrator doesn't want to pay over time to cover the rad tech's absence and tells doc to send her back to work. I'm sure this sort of thing goes on all the time where hospital related tests and treatments dollars are involved, as well. What's good for the bureaucracy's pocketbook can lead to influence brought to bear on a decision, whether we want to admit it or not.
  • The issues of corruption in the medical industry are as real as in any field. Downplaying..saying only a few..the preferential treatment shown some patients..the FBI has lists of thousands of arrests made. The legal system is no different. I think it is great that you defend your peers..just be careful. Ethnic, religious, politics..affect everyone. History has shown us this. JM
  • I believe the definition of corruption is a bit more expansive....forgive my minimizing it..a lot more expansive...
  • One of the so called dr.'s I saw..tell the nurse to F___ off...he thought I was backward for not thinking that was OK. Perhaps he was trying to incite violence...sick as far as I am concerned. Perhaps I should be given a mental health diagnosis..I believe the Chinese government does that kind of thing regularly! Different strokes for different folks Doctor!
  • Ever hear of the Blankenberg twins?
  • Check out "Dr. Joshua Baron"...
  • Better patient education and improved doctor-patient communication would help with a lot of the problems and misunderstandings.
  • Dr. Salwitz,with all due respect, doctors are simply people with a graduate degree. It does not automatically give them altruism. I have had problems because a doctor gave me impressions that weren't positive and is off telling other docs things about me that have nothing to do with medical care, and would be proven questionable or incorrect by the medical records. Rather than trying to fix the problem, apologize, he has opted to send police, lawyers, etc. after me. I have never ever sent the same in return. I have spoken out about my care and intend to keep doing so. They want that silenced. Do you think that this should be representative of physicians? I have several that provide excellent care to the best of their ability, but the loss of the care combined with other items means that I am left in the lurch. So much for ethics.
    • D Someya Reed
      Excellent point and observation (your first two lines)! I am so sorry to hear that ANY of your care was lost. That is despicable! I applaud you for having the courage and determination to speak out about your experiences. Nothing can ever change (i.e, improve) if we all remain silent or are silenced through intimidation and threats especially when made against those who are most in need of our help. Keep up the good, outspoken work. I, too, have been speaking out, both publicly and through legislative testimony, and will continue to do so even though I have received the same "lawyer threat" (from the practice's lawyer) as well as personal threats if I don't keep my mouth shut as I have been "told" to do. I simply took the threatening letter public to every related law enforcement and/or regulatory agency I could determine to have any measure of oversight or authority. Of course, even though I state nothing I cannot prove, I can be sued in civil court but as my story is true and my evidence solid I would gladly pit my evidence against that of the practice if they would like to take this to the next level (as they have threatened to do). It is unfortunate that we who do speak out get so little support from others and from even those who "say" they want to make things better or improve the system. Most often we are treated as outcasts, malcontents or worse. It will not cause me to veer from my path as I hope it won't for you. It is also unfortunate that you will likely never get an apology or see any attempt to correct the problem you encountered, at least, not from those who were responsible for it. In our case, an apology can never be given because I'm not the one who should receive that apology. The one who truly deserves an apology (and much better than she received) is dead. As far as fixable problems, Death is not among them. You deserve an apology and corrective measures to be taken. But in order to either apologize or fix a problem you have to recognize that a problem existed in the first place and take ownership of it. Too many times, as in our case and perhaps yours, those responsible either "pretend" that nothing happened or you were at fault or maybe even take it so far as to further pretend that you never existed at all. It is true that money corrupts and that power corrupts absolutely. Doctors have plenty of both...maybe not as much money as they personally might like but it certainly swirls around them in everything they do. If Dr. Salwitz is correct their power emanates from his frequent comment that nothing happens without a doctor's signature. So who is to blame when something goes wrong? Everyone still gets paid but you may or may not get the care you need. Money, in the end, will decide all...whether it's budgeted or not, cost vs. benefit, litigation potential, loss of future revenue or simply does this person have the personal resources to "push back" if we push him around. These things are not taught in medical school either but they certainly get a lot of air time in the real world. Are doctors corrupt? Some are, some aren't. To determine the percentages of each you'd have to refine the definition of the word. The dictionary definition states, "to make evil, rot or spoil." But in accepted use a different picture is painted. Corruption in the medical industry, of which doctors are a part, is a much larger percentage than we are led to believe here. Can doctors be corrupted? Now there's a much larger question especially if you include "Are they willing to compromise their principles?" Anyone who would do as you said was done to you in my book is corrupt. I wish you the best.
      • As I wish you the best also. Fabulous post. Wish you wrote for the local paper.
  • D Someya Reed
    QUESTIONS FOR DR. SALWITZ: Your opening statement(s)... "The major driver of excessive cost and poor quality medical care in the United States is the misalignment of financial incentives. In a fee-for-service environment doctors do more exams, order redundant tests, and perform unneeded treatments, because the more they do, the more they are paid." ...are you stating this as fact or hypothesis? If fact, then the logic of the rest of your argument falls apart as you claim that the "average" doctor doesn't work this way. Must keep in mind though that the average hospital (profit or non-) DOES as do a host of others who exert pressures or control over doctors. Now, I've also read that the major driver of excessive cost and poor quality medical care (for the same over-uses) is from doctors attempting to shield themselves from litigation. Which is it? You state there is no "secret rule" to not discuss earnings or how they are obtained but I'm sure you've heard many doctors, as have I, joke about it. Does "How do you think I paid for my new boat?" or "How do you think I put that new addition on my House?" ring any bells? No matter the item purchased, it's not really funny at all and especially if you are the patient that overhears it. Although doctors are people too and we all say some pretty inappropriate (and yes, even stupid stuff) from time to time. Back to your original statement, though, if that is not true (i.e., that doctors are largely altruistic and are NOT ordering extras for financial gain or otherwise) then what is it that anyone is trying to fix? Or, is this just a way to false-justify reducing doctor compensation and false-blaming doctors' methods in order to take the easy road to reducing overall medical costs? Doctors are a target since, as you say, nothing happens without their signature but not too many people think about what it might be that is driving that signature. I don't doubt your 100% NEVER statistic for yourself. But, you seem to think that every other doctor is like you with the exception of a few "baddies." Is this really realistic when extrapolated over the entire U.S. population of doctors?
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